Driftwood Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a care plan for two of the three sampled residents (Resident 52 and Resident 6) by failing to:A. Ensure Resident 52 had a care plan for impaired hearing. B. Ensure Resident 6 who had a diagnosis of post-traumatic stress disorder ([PTSD], a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it), had a care plan and included the use of psychotropic medications for mood disorders. These deficient practices had the potential to negatively affect the quality of life and wellbeing for Resident 6 and Resident 52 and could result in preventing them from achieving their highest practical well-being or needs not being met. Findings: A. During a review of Resident 52’s admission Record, the admission Record indicated Resident 52 was admitted to the facility on [DATE] with diagnoses including muscle weakness, type 2 diabetes mellitus (high blood sugar) and major…

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 listed on the oral medications' Emergency kit (Ekit) index (list) matched the medication found inside the Ekit.This failure had the potential to result in a delay in the administration of emergency medication and medication error.Findings: During an observation and concurrent interview with Registered Nurse (RN) 1 at Nurses' Station 1 of the Ekit on 8/7/2025 at 11:27 a.m., the medication listed on slot number 25 in the Ekit medication list indicated potassium chloride 20 milliequivalents (mEq, unit of weight). The medication observed in slot 25 was four tablets of nitrofurantoin 50 milligrams (mg, unit of weight). Registered Nurse (RN ) 1 stated the pharmacist verifies the Ekit contents when delivered to the facility. RN 1 stated if a medication was not in the Ekit, there was a risk for medication error, or delay in administration of the needed medication.During a telephone interview on 8/7/2025 at 11:47 a.m., the dispensing pharmacist (Pharmacist) stated Ekits were re-filled when a…

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 nursing staff failed to document monitoring on the medication administration record (MAR) for signs and symptoms of bleeding for one out of three residents (Resident 63) who is on Apixaban (a medication that thins the blood, prevents clots). This deficient practice had the potential to result in Resident 63 having blood in the stool or urine, bruising or severe headaches. Findings:During a review of Resident 63's admission Record (face sheet) dated 8/8/2025, the admission record indicated Resident 63 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypotension (low blood pressure), hyperlipidemia (high cholesterol) and atrial flutter (a heart rhythm disorder where the upper chambers of the heart beat very rapidly, typically between 250 and 350 times per minute).During a review of Resident 63's MDS dated [DATE], the MDS indicated Resident 63 was dependent (resident does none of the effort to complete the activity or…

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 protect the health, welfare, and rights for 94 of 94 residents by failing to implement the facility's written abuse policy and procedure (P&P) to suspend Certified Nurse Assistant (CNA) 1 and CNA 2 who were involved in the alleged abuse allegation. This deficient practice placed all residents at risk of abuse and had the potential for Resident 1 to feel unprotected and unsafe in the facility. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and cerebral infarction (when part of your brain dies its blood supply is cut off). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 5/26/2025, the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was intact and was dependent (helper does all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the personal belongs for one of two sampled resident's (Resident 1), who was discharged from the facility on 1/17/2025, were made available to Resident 1 and/or Resident 1's Responsible Party (RP) and/or Family Member (FM). This deficient practice resulted in Resident 1's being discharged to a Board and Care ([B&C] a type of small, residential facility that provides housing and personal care services to individuals who need assistance with ADLs) facility without her personal belongings and had the potential for Resident 1 to feel detached in her new environment. 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 of dementia a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/13/2024, the MDS indicated Resident 1 was unable to make decisions…

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), who was diagnosed with dementia (a progressive state of decline in mental abilities), and who lacked the capacity to understand and make decisions was discharged appropriately from the facility. This deficient practice resulted in Resident 1 being discharged to a Board and Care ([B&C] (a type of small, residential facility that provides housing and personal care services to individuals who need assistance with ADLs) facility on [DATE] without an Interdisciplinary Team (IDT] a team comprised of healthcare professionals from different discipline collaborating to develop and coordinate the residents' care plans such as a discharge plan with a goal to optimize the resident outcomes) discharge meeting, prior discharge planning, Resident 1's Responsible Party (RP) and/or Family Member (FM) provided with a Notice of Proposed Discharge/Transfer 30 days prior to the resident's transfer, assessment 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 four sampled residents (Resident 1) who was observed with a discoloration on her forehead, black eye and eye swelling was reported to California Department of Public Health (CDPH). This failure resulted in CDPH being unable to investigate Resident 1's injury of unknown origin in a timely manner Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease (a long term condition where the kidneys gradually lose their ability to filter waste and extra fluid from the blood), abnormalities of gait and mobility, dementia (a progressive state of decline in mental abilities) hypertension (HTN-high blood pressure) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's History and Physical (H&P), dated 4/26/2024, the H&P indicated Resident 1 did not…

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 four sampled residents (Resident 1) who was observed with discoloration on her forehead, black eye and eye swelling on 3/20/2025 was investigated into the history of her injury and to rule out abuse and neglect. This deficient practice had the potential to result in unidentified abuse and/or neglect in the facility and the failure to protect residents from abuse and neglect. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease (a long term condition where the kidneys gradually lose their ability to filter waste and extra fluid from the blood), abnormalities of gait and mobility, dementia (a progressive state of decline in mental abilities) hypertension (HTN-high blood pressure) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1 ' s History 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 one of three sampled residents (Resident 1) was free from sexual abuse. This deficient practice resulted in Resident 2 entering Resident 1's room unbeknownst to staff on 3/17/2025 at approximately 11 p.m., unfastening her (Resident 1's) incontinent brief and touching her private area, causing Resident 1 to feel scared and helpless. This deficient practice had the potential for Resident 1 to suffer emotional consequences and for other residents in the facility to be subject to the same abuse. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness. During a review of Resident 1's History and Physical (H/P), dated 3/8/2025, the H/P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS], a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct thorough investigation for one of three sampled residents (Resident 1), when they did not interview other residents in the facility, following an allegation made by Resident 1 that Resident 2 came to her room, which was confirmed by the facility's video surveillance, and touched her private parts. This deficient practice resulted in the inability of the facility to determine if Resident 2 had a behavior of entering other resident's rooms and touching them. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness. During a review of Resident 1's History and Physical (H&P), dated 3/8/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 3/14/2025, the MDS…

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

Based on interview and record review, the facility failed to ensure one of two sampled resident's (Resident 1) discharge planning and discharge procedures were implemented and documented prior to and when was Resident 1 was discharged from the facility (2/27/2025). This deficient practice resulted in Resident 1 being discharged from the facility without prior discharge planning or documentation that he received discharge instructions when he left the faciity on 2/27/2025. This deficient practice had the for Resident 1 to be unaware of his care needs and follow up appointments. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility 2/3/2025 with diagnosis including paraplegia (when a person is unable to move their lower body), anxiety disorder (a condition that involves persistent and excessive worry that interferes with daily activities), major depressive disorder ([MDD] a mood disorder that causes a persistent feeling of sadness and loss of interest), cannabis (marijuana) dependence and psychoactive…

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 three sampled residents (Resident 5) was supervised by the facility staff while smoking. This deficient practice resulted in Resident 5 smoking unsupervised on/near the facility's parking lot with the use of a cigarette lighter, without wearing a smoking apron, or having a receptacle to safely dispose of his used cigarette(s). This deficient practice had the potential for Resident 5 to sustain burn injuries. Findings: During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was admitted to the facility on [DATE] with diagnosis including cerebrovascular disease ([stroke] a condition that affects the blood flow to the brain), right side hemiplegia (complete paralysis of one side of the body), and glaucoma (an eye condition that damages the optic nerve that can lead to vision loss or blindness). During a review of Resident 5's Minimum Data Set ([MDS] a resident assessment tool) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Occupational Therapist (OT- a healthcare provider who helps a person meet goals to develop, recover, improve, and maintain skills needed for daily living and working) 1 accurately documented on the OT Discharge Summary Note the discharge goals for one of three sampled residents (Resident 3). OT 1 documented on 9/13/2024, Resident 3 tolerated thin hand rolled washcloth for four hours in her left hand without irritation or skin breakdown, when it should have been the documented for the right hand. This deficient practice resulted in inaccurate documentation of Resident 3's OT Discharge Summary Note and had the potential to affect Resident 3's plan of care and treatment. Findings: During a review of the Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted on [DATE] with the diagnosis of generalized muscle weakness. During a review of Resident 3's Minimum Data Set (MDS – a resident assessment…

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 resident (Resident 3) who had a designated Advocate (AD 1) was invited to participate in the Interdisciplinary Team Meeting ([IDT] a team of health care professionals from different disciplines who work together to provide care for a resident) to discuss and participate in the revision of the care plan (a document that summarizes a resident ' s health conditions, care needs, current treatments, goals, and action plan) for one out of three sampled residents (Resident 3). This deficient practice resulted in Resident 1 ' s AD 1 not attending the IDT meeting and had the potential to result in a care plan that was not person-centered (designed specifically around the individual needs, preferences and goals of the resident receiving care) and would not meet Resident 3 ' s needs. Findings: During a review of Resident 3 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 3 was originally admitted to the facility on [DATE] 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 two out of five sampled residents (Resident 3 and Resident 4), who were high-risk for falls, had wheelchairs that locked. This deficient practice had the potential to cause Resident ' s 3 and Resident 4 to sustain falls and injuries resulting from the fall such as a hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel), fractures (broken bones), hospitalization, and possible death resulting from complications of the fall. Findings: a. During a review of Resident 3 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation (a heart condition that causes an irregular and often rapid heartbeat in the upper chambers of the heart), thrombophilia (a condition which the body has a high probability of creating blood clots), functional…

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 provide a copy of medical records upon written request from an authorized legal representative ([LR] a person who is legally authorized to act on behalf of another) for one of five sampled residents (Resident 2) within two working days. This deficient practice violated Resident 2 ' s right to obtain a copy of their medical record and delayed their appeal to Health Insurance Provider (HIP) ' s decision to deny Resident 2 covered (paid for by insurance) stay at the facility. Findings: During a review of Resident 2 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 2 was originally 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), generalized muscle weakness, abnormalities with gait (a person ' s manner of walking) and mobility (the ability to move freely or lack thereof), and Charcot ' s…

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 retain, accurately document, systematically organize, and have readily accessible medical records for one of five sampled residents (Resident 2) according to the facility ' s policy and procedure (P&P) titled, Documentation Retention. This deficient practice had the potential Resident 2 to have unnecessary stress and fear of being kicked out of the facility due to Health Insurance Provider (HIP) not being given the clinical documents needed to support her continued insurance coverage to stay at the facility. Findings: During a review of Resident 2 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), generalized muscle weakness, abnormalities with gait (a person ' s manner of walking) and mobility (the ability to move freely or lack…

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 three sampled residents (Resident 1) was able to return to her room upon readmission from a General Acute Care Hospital (GACH). This failure resulted in Resident 1 experiencing frustration and sadness after being placed in a new room upon return from the GACH. Findings: During a review of Resident 1's admission record (Face Sheet), dated 9/27/2024, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including respiratory failure (a condition in which the blood doesn ' t have enough oxygen) and embolism (blood clot) of right femoral vein (a large blood vessel in the thigh). During a review of Resident 1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/14/2024, the MDS indicated Resident 1 had the ability to understand and be understood by others. During a review of Resident 1's Transfer Form, dated 9/25/2024, the Transfer Form indicated Resident 1 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 facility ice machine was cleaned and maintain per manufacturer guidelines for 83 out of 85 sampled residents. This deficient practice had the potential to cause the growth of microorganisms (an organism that can be seen only through a microscope) and could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization for all residents, staff, and visitors consuming the ice from the ice machine. Findings: During an observation and concurrent interview on 8/14/2024 at 2:41 p.m., with the Maintenance Supervisor (MS), the MS opened the ice machine door and wiped the soft black durometer trim (helps silence the ice bin door) attached to the ice storage bin using a clean white tissue paper. Observed the white tissue paper with brown in color after passing over the soft durometer trim. The MS stated…

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

Based on interview and record review, the facility failed to provide annual documentation including the Quality Assessment Assurance Committee([QAA] to develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] designated to bring about constant and measurable improvement in the services provided at the facility for continual improvement of quality care) team signatures to verify reviewing of their dietary department policies. This deficient practice had the potential for the facility staff to perform outdated practices. Findings: During a concurrent interview and record review on 8/16/2024 at 3:22 p.m. with the Dietary Supervisor (DS), the Manual Signature/Approval Form dated 1/3/23 was reviewed. The DS stated the Manual Signature/Approval Form dated 1/3/23 did not have a title to indicate which policies were being reviewed and stated this is the most recent review completed. The DS stated the policies are reviewed when the company tells them there are new policies coming. The DS was unable to…

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

Based on observation, interview, and record review, the Quality Assessment Assurance Committee([QAA] to develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] designated to bring about constant and measurable improvement in the services provided at the facility for continual improvement of quality care) failed to identify skills competencies of the dietary staff and assessments of the residents meal trays to ensure therapeutic diets were served as prescribed by the physician. This failure resulted in placing the residents at risk for not receiving the appropriate meal tray based on their diet orders and potentially choking on their food. Findings: During an interview on 8/19/2024, at 12:37 p.m., with the Director of Nursing (DON), the DON stated Dietary Supervisor (DS) should have noticed the wrong diets were being provided to the residents and brought it to the Administrators (ADM) attention. DON states QAA meetings are held to identify issues that are or potentially effecting 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 an observation, interview, and record review the facility failed to ensure nursing staff including licensed vocational nurses (LVNs) and certified nursing assistants (CNAs) were competent on food textures including physician prescribed diet of dysphagia (difficulty chewing and swallowing) minced and moist diet (mechanical-soft texture modified diet for difficulty chewing and swallowing) to ensure correct food consistency were distributed to seven of eight sampled residents (Resident 10, 11, 50, 53, 62, 81, and 83). This deficient practice resulted in Resident 10, 11, 50, 53, 62, 81, and 83 received a lunch tray on 8/14/2024 that contained a ground pimento cheese salad sandwich (sandwich included 2 slices of white bread, including the crust, with a scoop of ground pimento cheese in between the bread, sliced in half) while on a dysphagia minced and moist (ground) diet. This deficient practice placed Resident 10, 11, 50, 53, 62, 81, and 83 at risk for aspiration (when food, liquid, or other material enters a…

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: a. ensure follow up appointment for dental pain evaluation/ referral was completed for one out of two sampled residents (Resident 51). b. ensure follow up appointment for routine foot care podiatry (study of feet) evaluation/ referral was completed for one out of two sampled residents, Resident 56. These deficient practices resulted in a delay of necessary foot care and dental services. Findings: During a review of Resident 51's admission record ([Face sheet] a document that provides brief patient information), dated 8/16/2024, the face sheet indicated, Resident 51 was originally admitted on [DATE] and re- admitted on [DATE]. Diagnosis included Type 2 Diabetes Mellitus (chronic condition that affects how the body processes sugar) with chronic kidney disease ([CKD] a condition characterized by a gradual loss of kidney function over time), unspecified severe protein- calorie malnutrition (insufficient intake or absorption of food), legal…

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 dietary staff including the registered dietician (RD), dietary supervisor (DS), the cook (CK 1), and dietary aide (DA 1) were competent about preparing and serving a physician prescribed diet for dysphagia (difficulty chewing and swallowing) minced and moist diet (mechanical-soft texture modified diet for difficulty chewing and swallowing). As a result of this deficient practice, 7 out of 8 sampled residents (Resident 10, resident 11, Resident 50, Resident 53, Resident 62, Resident 81, and Resident 83) on a dysphagia minced and moist (ground) diet received a lunch tray on 8/14/2024 that contained a ground pimento cheese salad sandwich (sandwich included 2 slices of white bread, including the crust, with a scoop of ground pimento cheese in between the bread, sliced in half). This deficient practice placed Resident 10, Resident 11, Resident 50, Resident 53, Resident 62, Resident 81, and Resident 83 at risk for aspiration (breathing 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 resident's medical records were updated to show documentation that an advance directive (legal document that states your wishes for medical care if you are unable to communicate with them due to illness or injury) was discussed and written information was provided to the resident or responsible party for one out of three sampled residents (Resident 72). This failure resulted in a violation of the residents' and/or residents representatives' right to be fully informed of the option to formulate their advance directive and had the potential to cause conflict with the resident's wishes regarding health care. Findings: During a review of Resident 72's admission Record, Resident 72 was admitted [DATE], with a diagnosis of encephalopathy (damage or disease that affects the brain), intracerebral hemorrhage (a type of stroke that causes bleeding in your head) and heart failure (heart doesn't pump enough blood for your body's needs). During a review 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 observation, interview, and record review, the facility failed to assess mental capacity (ability to make decisions) and provide information to one of three sampled residents (Resident 83) before signing the arbitration agreement (AA- a way of resolving a dispute without filing a lawsuit and going to court). This failure had the potential to result in Resident 83 not fully understanding their right to limit opportunities to initiate judicial proceedings that challenge unfavorable decisions. Findings: During a review of Resident 83's admission Record, the admission Record indicated, Resident 83 was admitted to the facility on [DATE] with diagnosis including Fetal Alcohol Syndrome (FAS- a condition in a child that results from alcohol exposure during the mother's pregnancy) and autistic disorder (developmental disability that affects how the brain processes information and how people communicate and interact with the world). During a review of Resident 83's Minimum Data Set (MDS- a standardized assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure an interdisciplinary team meeting (conference discussing the residents care plan comprised of different members of the healthcare team from different specialties]), including one of three sampled resident (Resident 1) and Resident 1's Responsible Party (RP1), convened to discuss the status of Resident 1's hearing loss, pending audiologist (specialists who evaluate, diagnose, treat, and manage hearing loss) appointment, and status of the requested hearing aids (sound amplifying device used to assist people with hearing loss). These deficient practices violated Resident 1's rights and resulted in Resident 1 and RP 1 feeling frustrated leading to a potential decline in Resident 1's psychosocial health. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses including unspecified hearing loss and major depressive disorder…

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), who had hearing loss and requested hearing aids (sound amplifying device used to assist people with hearing loss) had an appointment with the audiologist (specialists who evaluate, diagnose, treat, and manage hearing loss) to perform an audiogram (hearing test) after the Otolaryngologist (specialist who treats conditions of the ears, nose and throat) ordered for the resident to see the audiologist on 1/5/2024. These deficient practices resulted in a delay in the process for Resident 1 to acquire hearing aids leading to a potential decline in Resident 1's psychosocial health. As of 5/8/2024, four months after the order was made, Resident 1 has not had the audiogram. 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] and readmitted on [DATE] with diagnoses including hypertensive heart disease (high blood…

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 records were provided within 48 hours following a request by Responsible Party 1(RP 1) for one out of two sampled residents (Resident 1). This deficient practice resulted in the inability of Resident 1 and/or Resident 1's RP to access requested records and violated Resident 1's rights to have access to his records. Findings: During a review of Resident 1's admission records (Face sheet), the Face Sheet indicated, Resident 1 was originally admitted on [DATE] and re- admitted on [DATE] with a diagnosis including spondylosis (a small crack between two back bones in your spine) without myelopathy (an injury to the back bones caused by severe compression), cervical region (neck region of your back bone), chronic diastolic (the pause between heart beats) heart failure (heart's capacity to pump blood cannot keep up with the body's need), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, 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 perform hand hygiene before applying new gloves when cleaning the gastrostomy tube ([G- tube]-a tube inserted through the wall of the abdomen directly into the stomach) and applying a dry dressing for one out three sampled residents, Resident 2. This deficient practice had the potential to cause cross contamination (transfer of germs from one object to another) and cause a serious skin infection. Findings: During a review of Resident 2 admission record (face sheet), dated 3/20/24, the face sheet indicated, Resident 2 was originally admitted on [DATE] and re-admitted on [DATE] with the diagnosis including adult failure to thrive (a state of decline that is multifactorial may be caused by chronic concurrent diseases and functional impairments), dysphagia (difficulty swallowing), encounter for attention to gastrostomy (an artificial entrance to the stomach attended to), cellulitis of abdominal wall (a common potentially serious bacterial sin…

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 a. Failed to develop individualized interventions for one of three resident's (Resident 1's) care plan to prevent falls, and b. Failed to develop a care plan for one of three resident's (Resident 1) noncompliance with the use of call lights and noncompliance with ambulating without assistance. This deficient practice placed Resident 1 at higher risk for falls. Findings: During a review of Resident 1 ' s admission record, dated 9/21/2023, the admission record indicated Resident 1 was admitted on [DATE] with the diagnosis including generalized muscle weakness, anemia (a condition in which there are too few red blood cells to carry oxygen to the body ' s tissues), other abnormalities of gait and mobility (an unusual walking pattern that may be caused by underlying health conditions. During a review of Resident 1 ' s H&P, dated 8/28/2023, the H&P indicated Resident 1 presented to the General Acute Care Hospital (GACH) emergency room (ER) for generalized weakness 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 one of one resident's( Resident 1) fall risk evaluation, dated 8/19/2023, was accurate. The deficient practice resulted in an incorrect depiction of Resident 1's fall risk and potentially impacted the care rendered and received by Resident 1. Findings: During a review of Resident 1 ' s admission record, dated 9/21/2023, the admission record indicated Resident 1 was admitted on [DATE] with a diagnosis including generalized muscle weakness, anemia (a condition in which there are too few red blood cells to carry oxygen to the body ' s tissues), other abnormalities of gait and mobility (an unusual walking pattern that may be caused by underlying health conditions. During a review of Resident 1 ' s history and physical (H&P), dated 8/28/2023, the H&P indicated Resident 1 presented to the General Acute Care Hospital (GACH) emergency room (ER) for generalized weakness and a fall at home. During a review of Resident 1 ' s Minimum Data Set ( MDS- a…

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 accommodate the needs of one of two sampled residents (Resident 1) by not addressing the noise of a low air loss mattress ([LAL] mattress powered by a pump or blower system used to reduce pressure in the skin) in resident ' s room. This failure had the potential to place Resident 1 at risk for discomfort and ringing of ears. Findings: During a review of Resident 2 ' s face sheet, the face sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection (common infection of the body ' s drainage system for removing urine) During a review of Resident 2 ' s Minimum Data Set, dated [DATE], the MDS indicated Resident 2 ' s cognition (thought process) and Resident 2 required limited assistance with eating, required extensive assistance with dressing, and was totally dependent on staff for personal hygiene and toilet use. personal hygiene and dressing. During an observation on 8/1/2023 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a functioning call light (alerting device used by patients to signal assistance from staff members) of one of three sampled residents (Resident 3). This failure had a potential to place Resident 3 at risk for accidents and a delay in meeting the resident ' s needs for assistance. Findings: During a review of Resident 3 ' s admission Record (Face Sheet), the face sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis that included morbid obesity (overweight), muscle weakness and chronic obstructive pulmonary disease ([COPD] group of lung diseases that block the airflow and make it difficult to breathe). During a review of Resident 3 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 7/31/2023, the MDS indicated Resident 3 was able to make independent decisions that were reasonable and consistent. The MDS indicated Resident 3 required two persons assist with bed mobility,…

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 an infection control program which prevents the spread of infection and COVID-19 (a respiratory disease caused by a coronavirus called SARS-CoV-2) when: a. Staff failed to complete a self-screen for temperature and symptoms of COVID-19 prior to starting their shift. b. Staff failed to [NAME] and Doff before entering a contact precaution room (Resident 23). This deficient practice could potentially spread and expose residents and staff to COVID-19. Findings: During an interview on 12/4/2021, at 9:00 am, with Screener/Restorative Nurse Assistant (Scr/RNA) 2 stated the process for screening staff upon entering the facility was self-screening and logging of temperature on the screening log. Staff members proceed to perform hand hygiene after self-screening for temperature and symptoms of COVID-19. During a concurrent interview and record review, on 12/4/2021 at 9:20 am, with the Scr/RNA 2 the daily visitors, vendors and medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure three of three sample residents' (15, 25, 59) call lights were within reach. For residents 15, 25, and 59, their call lights were lying on the floor underneath the residents' beds. This deficient practice had the potential to prevent Residents 15, 25, and 59 from maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preferences. Findings: 1. During a review of Resident 15's admission Record, the record indicated the resident was originally admitted to the facility on [DATE]. Resident 15's diagnoses included: history of a stroke, vascular dementia (a progressive loss of brain function affecting memory, thinking, and behavior that interferes with daily functioning, caused by a stroke) and diabetes mellitus (abnormal blood sugar). During a review of Resident 15's Minimum Data Set (MDS), a standardized assessment and care screening tool, 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 interview and record review, the facility failed to ensure one of three randomly selected residents (Residents 28) reviewed for changes in Medicare coverage were provided with the Notice of Medicare Non-Coverage (NOMNC) appeal process in a timely manner. This deficient practice had the potential to result in responsible parties not being able to exercise their right to file an appeal. Findings: During a review of Resident 28's SNF Beneficiary Protection Notification Review form indicated the resident last covered day for Medicare Part A Skilled Services was 11/14/2021. SNF Beneficiary Protection Notification Review form indicated Notice of Medicare Non-Coverage (NOMNC) form was not given. During an interview on 12/6/2021, at 9:09 a.m., with Social Services Director ( SSD), SSD stated, that NOMNC form needs to be given to resident 72 hours prior to last day covered Medicare. SSD stated that resident and/or resident representative should receive NOMNC appeal process information. SSD stated that she did not give Resident 28 NOMNC for prior to discharge. During an interview 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 and interview, the facility failed to provide one of one residents (34) privacy during wound care. Resident 34's privacy curtain would not pull completely to the end of the track, exposing Resident 34 to the hallway. This deficient practice did not allow Resident 34 the right to privacy during care. Findings: During a review of Resident 34's admission Record, the record indicated the resident was originally admitted to the facility on [DATE]. Resident 34's diagnoses included: pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure) in the sacral region (near buttocks), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), functional quadriplegia (a loss of sensation, function, or movement in arms and/or legs). During a review of Resident 34's Minimum Data Set (MDS), a standardized assessment and care screening tool,…

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 Resident 41's lost prescription reading glasses was resolved in a timely manner. This deficient practice resulted in the resident having decreased vision and negatively affected the resident's quality of life. Findings: On 12/02/21 at 10:06 a.m. during an interview with Resident 41, the resident stated she lost her eye glasses, and had reported the loss to her nurse. Resident 41 stated the facility staff do not attempt to find her belongings or reimburse her when she reportsed her items lost. The resident stated she does not feel good about not seeing clearly without her eye glasses. On 12/06/21 at 8:44 a.m. during an interview with the Certified Nurse Assistant (CNA 11), the CNA stated when a resident reports a lost item, she would look for the item in the closet, check the laundry and talk to the charge nurse if she could not find the item. On 12/06/21 at 8:50 a.m. during an interview with the Licensed Vocational Nurse (LVN 1) the LVN stated when a resident reports a lost item, she would look in the laundry 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 develop a comprehensive, resident-centered care plan for two of two residents (Resident 41 and 75). a. Resident 41 had impaired vision and did not have a care plan to address the impaired vision. b. Resident 75 had an intravenous (IV) site and was receiving IV iron (Venofer) for anemia, however, there was no care plan for the IV site and no care plan for receiving iron with a diagnosis of anemia. These deficient practices placed the residents at risk for harm and injury and impact the residents' quality of care. Findings: a. On 12/02/2021 at 10:06 a.m. during an interview with Resident 41, the resident stated her vision was terrible, she saw double and does not feel good about not seeing clearly. On 12/06/2021 at 10:00 a.m. during an interview with the Director of Nursing (DON), the DON stated when a resident had impaired vision the process was to call the medical doctor (MD) to get an order to be seen by the eyes, ears, nose and throat…

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 the correct volume of oxygen ordered by the physician for one (1) out of the two (2) sampled residents (Resident 42). This deficient practice resulted in Resident 42 receiving incorrect oxygen than required and can negatively impact the resident's health and well-being. During a review of the Resident's 42 admission record (Face Sheet), the face sheet indicated Resident 42 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 42 diagnoses included acute kidney failure (kidneys are not working well), acute respiratory failure with hypoxia (not enough oxygen in the blood), partial intestinal obstruction (food is prevented from passing normally through the bowel). During a review of Resident 42 's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/30/2021, the MDS indicated Resident 42 had severe impairment in cognitive (ability to learn, remember, understand, and make decision)…

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 foot care for one of one residents (75). The toe nails on Resident 75's two big toes were long and curved. The facility did not know the last time Resident 75 had seen a podiatrist. This deficient practice had the potential to cause Resident 75 to experience discomfort and complications with mobility and foot health. Findings: During a review of Resident 75's admission Record, the record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 75's diagnoses included: history of a stroke, blood clots in the legs, chronic obstructive pulmonary disease ([COPD] a progressive lung disease that causes coughing, wheezing, shortness of breath and makes it difficult to breath), heart failure and diabetes mellitus (disease in which blood glucose/blood sugar levels are too high). During a review of Resident 75's Minimum Data Set (MDS), a standardized assessment and care screening tool,…

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 accurately record fluid intake for one of one sampled resident (Resident 11) with fluid restrictions. This deficient practice had the potential to cause fluid overload or swelling for Resident 11. Findings: During a review of the Resident's 11 admission record (Face Sheet), the face sheet indicated Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 11 diagnoses included acute on chronic congestive heart failure ([CHF] heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), chronic kidney disease Stage 3 (kidneys are not working well), acute respiratory failure with hypoxia (not enough oxygen in the blood). During a review of Resident 11 's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/16/2021, the MDS indicated Resident 11 had moderate impairment in cognitive (ability to learn, remember, understand, and make decision) skills 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 and interview, the facility failed to date/label a peripheral intravenous (IV) site dressing for one of one residents (75), per facility policy and staff were unsure how often the dressing should be changed. This deficient practice had the potential for Resident 75 to experience medication leaking around the IV insertion site, redness, swelling, and infection at the IV site. Findings: During a review of Resident 75's admission Record, the record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 75's diagnoses included: history of a stroke, blood clots in the legs, heart failure, diabetes mellitus (disease in which blood glucose/blood sugar levels are too high) and anemia (low number of red blood cells). During a review of Resident 75's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/11/2021, the MDS indicated Resident 75's cognition (mental capacity to make decisions, ability to remember, learn,…

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 a. ensure oxygen tubing was labelled with a change date for one of one resident (Resident 42). This deficient practice had the potential for complications associated with oxygen therapy for the resident. b. follows their policy and procedure for displaying a No smoking on the door for two of two sample residents (Resident 42 and 62) who was receiving oxygen therapy. This deficient practice had the potential to place residents at risk of injury due to a fire hazard. Findings: a. During a review of the Resident's 42 admission record (Face Sheet), the face sheet indicated Resident 42 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 42 diagnoses included acute kidney failure (kidneys are not working well), acute respiratory failure with hypoxia (not enough oxygen in the blood), partial intestinal obstruction (food is prevented from passing normally through the bowel). During a review of Resident 42 's Minimum Data Set…

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 staff failed to reassess the pain level (intensity) to determine if one of one resident (Resident 177) could benefit from an as needed pain medication in between the routine pain medications to ensure the breakthrough pain was relieved. This deficient practice resulted in Resident 's 177 experiencing pain during dressing changes. Findings: During a review of the Resident's admission record (Face Sheet), the face sheet indicated Resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident diagnoses included acute kidney failure (kidneys are not working well), cellulitis (skin infection) of right and left lower limb, Type 2 diabetes mellitus (a condition in which the body fails to metabolize (process) glucose (sugar) correctly), pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (tailbone). During a review of Resident '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.

Based on observation, interview, and record review, the facility failed to ensure staffing information was posted and in a visible and prominent place on a daily basis. As a result, the total number of staff and the actual hours worked by staff was not readily accessible to residents and visitors. Findings: During an observation on 12/3/21 at 1: 50 p.m., no visible nursing staffing posting was present at Nursing Station. During an observation 12/6/21 at 10:26 a.m., nursing staffing was posted on a white stand in a clear covered plastic protector at one side of the nursing station. During an interview with DON on 12/6/21 at 10:26 a.m. regarding posted staffing, DON replied, Usually HR posts daily staffing numbers; HR calculates everything for how many nursing hours and posts it every day. HR is also responsible for keeping track of previous postings. During the interview, DON stated, The purpose of posting the staffing is so we will know how many hours for nursing. It is near the nursing station on this white stand covered with the plastic at the side of nursing station. DON states,…

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 staff failed to ensure that it is free of a medication error rate of less than five percent as evidenced by the identification of two out of two medication errors based on 27 medication opportunities, that yield a facility medication error rate of 7.41percent during medication administration. The following two medication errors occurred for: 1. The facility failed to administer scheduled blood pressure medications for Resident 16 as ordered. 2. The facility failed to administer full dose of medication for Resident 69 as ordered. This deficient practice had a potential to place two out of two resident's at risk for causing the resident discomfort and/or jeopardizes his or her health and safety. Findings: a. During a review of the admission record dated December 6, 2021, Resident 69 (R69) was admitted to the facility on [DATE] for intestinal obstruction/partial ileus (a painful obstruction of the intestine) and paraplegia (paralysis of the legs 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 three out of three residents were free from significant medication error by failing to: 1. To administer scheduled blood pressure medications as ordered. 2. To administer full dose of medication as ordered. 3. Ensure medications at resident bedside had a physician order. This deficient practice had a potential to place four out of four residents' at risk for causing the resident discomfort or jeopardizes his or her health and safety. Findings: a. During a review of the admission record dated December 6, 2021, Resident 69 (R69) was admitted to the facility on [DATE] for intestinal obstruction/partial ileus (a painful obstruction of the intestine) and paraplegia (paralysis of the legs and lower body). During a review of the Minimum Date Sheet (MDS - a comprehensive assessment and care-planning tool) dated November 1, 2021 indicated Resident 69 memory is intact and is alert and oriented. During a concurrent observation and interview 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 observation, interview and record review, the facility staff failed to ensure medications were stored in accordance with current accepted professional standards in the medication storage room by failing to dispose of two of two expired oral (given by mouth) medications in station 3 medication storage room and insulin being opened past 28 days. These deficient practice resulted in unsafe storage of the medication, the potential to administer altered medication potency and strength to residents and could have resulted in medication errors. Findings: a. During an observation 12/2/21 at 10:30 a.m.in the medication storage room in station 3, it was observed that two medications were expired. The medications were Meclizine and Oyster shell calcium. The dates were 6/21/21 for the Oyster shell vitamin supplement and 7/21/21 for the Meclizine tablets. During an interview on 12/2/21 at 10:55 a.m. with Central Supply (CS) it was stated that CS orders office and medication supplies. CS stated, I order from Twin Med pharmacy on Monday's and they deliver on Tuesday. CS stated, I put 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 observation, interview, and record review the facility failed to maintain dish washer temperature 120 degrees Fahrenheit as outline in the facility policy. This deficient act placed residents at increased risk for food borne illness related to improper sanitation dishes. Findings: During an observation of the kitchen dish washer on 12/3/21 on 08:32am, it was noted that during the wash cycle water temperatures did not exceed 118 degrees Fahrenheit. During an interview on 12/06/21 at 12:12pm the Dietary Supervisor (DSS) stated that he was unaware why the water temperature did not exceed 118 degrees Fahrenheit as it is checked daily by kitchen staff. DSS stated the dish wash temperature should reach between 120-130 degrees Fahrenheit or higher for proper sanitation. DSS continued, stating that he will alert the maintenance department to repair the issue immediately. A review of facility policy revised October 01, 2014 titled, Dish Machine Temperature Recording, indicated that low temperature washers must maintain a temperature between 120-150 degrees Fahrenheit during both 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 complete a process to identify, track, and evaluate effectiveness of antibiotic administration for four of four residents (Residents 69, 237, 238, and 239) from April 2021 through November 2021. This deficient practice has the potential to increase antibiotic resistance and provide antibiotics without justification in violation of the standard of care. Findings: During an interview on 12/2/21 at 8:00 a.m., the facility RN. Sup1 stated that the forms in the Infection Control binder were all of the tracking that the facility had but were not the forms used by facility Medical Director and DON during their meetings for facility infection surveillance. RN. Sup1 asked the DSD to obtain the computerized summation forms used by the Medical Director and DON for facility antibiotic tracking. DSD printed the Monthly Analysis of Infections Forms from the computer. The section of the Infections Form labeled, number of infections by organism was not completed…

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 an infection control program which prevents the spread of COVID-19 (a respiratory disease caused by a coronavirus called SARS-CoV-2) when Resident 42 were not tested with COVID 19 when he had symptoms consistent with COVID 19. This deficient practice could potentially spread and expose resident and staff with COVID-19. Findings: During a review of the Resident's 42 admission record (Face Sheet), the face sheet indicated Resident 42 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 42 diagnoses included acute kidney failure (kidneys are not working well), acute respiratory failure with hypoxia (not enough oxygen in the blood), partial intestinal obstruction (food is prevented from passing normally through the bowel). During a review of Resident 42 's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/30/2021, the MDS indicated Resident 42 had severe impairment in cognitive…

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 that freezer thermometer was working. This deficient practice place residents at increased risk for food borne illness related to improper temperature control of frozen food. Findings: During the initial kitchen tour on 12/02/21 at 07:57am it was noted that the thermometer in freezer number 5 read 30 degrees Fahrenheit. During an interview on 12/02/21 at 08:07am the Dietary Supervisor (DSS) stated that the thermometer was broken and would be removed and replaced immediately. DSS admits the staff utilize the thermometer daily to monitor freezer temperature. DSS stated that staff should have checked and removed thermometer to ensure the integrity of the frozen foods to prevent possible health complication secondary to ingesting food not maintained at appropriate temperatures. A review of facility policy revised November 1, 2014, titled, Refrigerator/Freezer Temperature Records indicated Note on the temperature forms the plan of action taken when temperatures are not in acceptable range.