Harbor Post Acute Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 10) had a low air loss mattress on the appropriate setting.This deficient practice had the potential for Resident 10 to develop a pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence).Findings:During a review of Resident 10's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 10 was admitted on [DATE] with diagnoses that included malignant neoplasm of the bladder (bladder cancer), absence of right upper limb below elbow, osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and intervertebral disc degeneration (a condition where the spinal discs, which act as cushions between vertebrae, break down and lose their ability to absorb shock effectively).During a review of Resident 10's History and Physical (H&P), dated 4/10/2025,…

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 one of two sampled residents (Resident 34) oxygen delivery equipment was labeled and changed in accordance with the current accepted professional standards of practice. 2. Ensure one of five sampled residents' (Resident 59) tubing for the nebulizer machine (medical device that converts liquid medication into a fine mist, allowing it to be inhaled directly into the lungs) was changed every seven days per facility protocol. These deficient practices had the potential for Resident 34 and Resident 59 to experience complications such as infection associated with oxygen therapy.Findings: 1. During a review of Resident 34’s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 34 was admitted on [DATE] with diagnoses that included end stage renal disease (End Stage Renal Disease-irreversible kidney failure), and anemia (a condition where the body does…

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 an effective pain management on one of one sampled resident (Resident 14) by failing to:1. Ensure Resident 14's pain level was assessed after administering pain medication. This deficient practice placed Resident 14 at risk for inadequate pain relief and delay of care. Findings: During a review of Resident 14's admission Record (front page of the chart that contains basic information of the resident), the admission Record indicated, Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14's diagnoses included chronic (something that continues over an extended period of time) back pain, generalized osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and generalized muscle weakness. During a review of Resident 14's History and Physical (H&P), dated 7/3/2025, the H&P indicated, Resident 14 had the capacity to understand and make decisions. 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 interview and record review, the facility failed to ensure a resident who received hemodialysis ([HD] - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment received care in accordance with standards of practice for one of five sampled residents (Resident 1) by failing to:1. Communicate to dialysis center staff regarding Resident 1's change of condition. This deficient practice had the potential to result in a delay or lack of coordination of dialysis care and services to Resident 1. Findings:During a review of Resident 1's admission Record (front page of the chart that contains basic information of the resident), the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included End Stage Renal Disease ([ESRD] - irreversible kidney failure), hemodialysis ([HD] - a treatment to cleanse the blood of wastes and extra fluids artificially through…

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 one of five sampled residents (Resident 3) received Furosemide ([diuretic]- medication used to remove excess fluid from the body) by the route ordered by the physician.This deficient practice had the potential for Resident 3 to have an adverse effect (bad outcome) after receiving the medication.During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with a readmission on [DATE]. Resident 3's diagnoses included congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and obesity.During a review of Resident 3's History and Physical (H&P), dated 1/30/2024, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 7/22/2025, the MDS indicated Resident 3 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 interview and record review, the facility failed to: 1. Ensure one of five sampled residents (Resident 27) had a Hemoglobin A1C ([HgA1C] - a blood test that measures the average blood sugar level over the past two to three months) completed every three months per physician's order.This deficient practice resulted in inadequate monitoring of Resident 27's diabetes ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was admitted to the facility on [DATE], with a readmission on [DATE]. Resident 27's diagnoses included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 27's Minimum Data Set (MDS - a resident assessment tool), dated 7/25/2025, the MDS indicated Resident 27 was able to express ideas/wants and able to understand others. The MDS indicated Resident 27 was dependent (helper does…

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 recognize severe weight loss that was experienced by one of three sampled residents (Resident 1), when Resident 1 went from 92 pounds (lbs.), on 4/7/2025 to 72.75 lbs. on 5/5/2025 (a weight loss of 19.25 lbs. in less than a month). The facility failed to: 1. Ensure there were no discrepancies in the calculation of the percentage of food Resident 1 consumed between 4/14/2025 and 5/4/2025 when the Weekly Summary Nurse Progress Note indicated Resident 1's food intake was between 51% to 100% versus the Document Survey Report that indicated Resident 1's food intake was 38.9% to 71.4%. 2. Follow Resident 1's Care Plan interventions to monitor Resident 1's weight loss/gain of three lbs. in a week and five lbs. in one month. 3. Notify Resident 1's physician and the facility's Registered Dietician (RD) 1 of Resident 1's poor dietary intake resulting in a severe weight loss of 19.25 lbs. in less than 30 days. 4. Give clear instructions on how to calculate 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 administer a medication, Tacrolimus (a drug that suppresses the immune system to prevent organ rejection), as ordered by a physician for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1, who was a lung transplant (a surgical procedure where one or both of a resident's diseased or damaged lungs were replaced with healthy lungs from a deceased donor) recipient, not receiving Tacrolimus and had the potential to cause harm/rejection to Resident 1's transplanted lung. 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 lung transplant status. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated [DATE], the MDS indicated Resident 1 had mild cognitive impairment (a brain condition that causes noticeable but mild memory and thinking problems). 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 the volume on their call lights was not turned down and audible. to ensure one of the facility's call light system was efficiently functioning. On 2/19/2025, the call light system in one of two nursing stations in the facility was not audible in Resident 3's care area and the facility's hallways. This deficient practice resulted in the facility's call light system not being audible in Resident 3's care areas and throughout the hallway. This deficient practice had the potential for the Resident 3's care needs to be neglected. 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 heart failure (a life threatening condition that occurs when the heart suddenly can't pump enough blood not the body) and chronic respiratory failure (a serious condition that makes it difficult for a person to breathe on his/her own). During…

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 five sampled residents (Resident 1) who was transferred to a General Acute Care Hospital (GACH) on 1/21/2025 due to shortness of breath (SOB) was readmitted to the facility when the GACH cleared him to return to the facility on 1/31/2025. This deficient practice resulted in Resident 1 remaining at a GACH for 22 days beyond the date the GACH attempted to transfer him back to the facility. This deficient practice had the potential for Resident 1's continuity of care to be interrupted. 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 heart failure (a life threatening condition that occurs when the heart suddenly can't pump enough blood not the body) and chronic respiratory failure (a serious condition that makes it difficult for a person to breathe on his/her own). During a review of Resident 1's Minimum Data…

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 immediately report a resident-to-resident altercation to the California Department of Public Health (CDPH), and the State Long Term Care Ombudsman (an agency that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) within the regulated time frame of two hours, for two of two sampled residents (Resident 1 and Resident 2). This deficient practice resulted in CDPH ' s inability to investigate the allegations of abuse timely and had the potential for other allegations of abuse to go unreported. a. During a review of the Resident 1 ' s admission record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage (a stroke caused by a ruptured blood vessel), hemiplegia (severe muscle weakness) and hemiparesis (muscle weakness) following cerebrovascular disease (group of disorders that affect…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse policy and procedure by failing to investigate a resident-to-resident altercation between two of two sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from ongoing or further abuse. a. During a review of the Resident 1 ' s admission record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage (a stroke caused by a ruptured blood vessel), hemiplegia (severe muscle weakness) and hemiparesis (muscle weakness) following cerebrovascular disease (group of disorders that affect blood supply to the brain) affecting the dominant right side, frontal lobe (responsible for functions ex: emotions, memory) and executive function (set of cognitive skills that helps control behavior) following cerebral infarction (disruption of 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 observation, interview and record review, the facility failed to follow one of three residents ' (Resident 1) care plan, when Restorative Nursing Assistant 1 (RNA 1) transferred Resident 1 from the wheelchair to the bed by himself. This deficient practice has the potential for Resident 1 to experience a fall or injury. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted on [DATE] with the diagnosis including hemiplegia (weakness on one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (disrupted blood flow to the brain). During a review of Resident 1 ' s Minimum Data Set ([MDS]- a standardized assessment and care screening tool) dated 7/25/2024, the MDS indicated Resident 1 ' s cognition (the mental processes that take place in the brain, including thinking, attention, language, learning, memory and perception) was intact and required substantial/ maximal assistance (helper does…

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 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, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 106 out 108 total residents in the facility by not: A. Ensuring Foods were dated, labeled, and discarded before the used by date (expiration dates). B. Ensuring Dietary Aid (DA) 2 performed hand hygiene (washing hands) and changed gloves between tasks during tray line (Resident's trays are assembled and check for accuracy before food is delivered to them). C. Ensuring [NAME] 2 took off her wristwatch that was not covered with gloves during tray line. These failures had the potential to affect residents and result in pathogen (germ) exposure and placed residents at risk for developing foodborne illness (food…

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 care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for four of 24 sampled residents (Resident 26,27, and 213). The facility failed to: a. Ensure privacy curtain was drawn while providing care with Resident 26 and 27. b. Ensure Resident 213 indwelling urinary bag was covered completely with a privacy bag. These deficient practices had the potential to feel embarrassed and affect the self-esteem, self-worth, sense of independence and psychosocial well-being for Resident 26,27, and 213. Findings: a.During a review of Resident 26's admission Order, the admission Record indicated Resident 26 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including type 2 diabetes mellitus (a condition in which the body fails to process glucose (sugar) correctly ), heart failure (a condition that develops when your heart doesn't pump enough blood 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 staff failed to ensure call light was within reach for two of three sampled residents (Resident 12 and Resident 16). This deficient practice had the potential for Resident 12 and 16 not to receive necessary assistance when needed, and experienced loss of self-esteem. Findings: During a review of Resident 16's admission Order, the admission Record indicated Resident 12 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus (a condition in which the body fails to process glucose (sugar) correctly), unspecified dementia (loss of memory, language, problem-solving and other thinking abilities), and anxiety disorder (excessive worry and feelings of fear, dread, and uneasiness). During a review of Resident 16's Minimum Data Sheet (MDS- a standardized assessment and care screening tool) dated 04/02/2024 indicated Resident 16 had severe cognitive (ability to learn, understand, and make decisions) impairment and requires…

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 a resident Minimum Data Set ([MDS] a comprehensive assessment and care screening tool) assessment was transmitted within 14 days after completion for two of 14 sampled residents (Resident 69 and 83). This deficient practice had the potential to the delay in identifying resident care concerns needing individualized care plan, delay in providing residents interventions necessary to provide quality care and delay in the reimbursement process. Findings: During a review of MDS submission form for Resident 69 dated 05/16/2024 and Resident 83 dated 06/24/2024, indicated the assessment completion was late and it was more than fourteen days beyond what was required. During an interview on 08/07/2024 at 1:48 p.m., the MDS Coordinator stated Resident 69 and 83's MDS discharge assessment from the hospital was submitted after fourteen days and the regulation requires to submit within fourteen days. The MDS Coordinator admitted that there was a late submission of Resident 69 and 83's discharge assessment. MDS Coordinator 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide social services to three out of five sample residents (Resident 37, 93 and 94) by: a Failing to follow up on the advanced directive for Resident 37. b. Failed to follow up with dentures for Resident 93. c. Ensure Resident 94 was seen by a podiatrist (a provider who specializes in caring for the feet, ankles, and lower legs). This deficient practice had the potential to cause conflict with a resident's wishes regarding healthcare, delay the delivery of care and services, and affect the resident's psychosocial negatively. The failure of resident 94 not seen by podiatrist resulted in not having her toenail cut for six months and experience pain on her right 5th toe. Findings: a. During a review of Resident 37's Face Sheet (admission record), the Face Sheet indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including muscular dystrophy (group of diseases that cause progressive weakness and muscle mass loss), traumatic brain…

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 interviews, the facility failed to appropriately store medications that required refrigeration for two of two sampled residents (Resident 80 and 5). This deficient practice had the potential for loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages. Findings: a. During a review of Resident 80's Face Sheet (admission record), the Face Sheet indicated Resident 80 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Type two (2) diabetes mellitus (DM: body has trouble controlling blood sugar)with diabetic neuropathy (nerve damage caused by diabetes), and anemia (not having enough healthy red blood cells to carry oxygen throughout the body). During a review of Resident 80's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 7/11/2024, the MDS indicated Resident 80's cognitive skills (the mental action or process of acquiring knowledge and understanding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement infection control measures by failing to: A. ensure gowns were worn for two of 24 sampled residents (Resident 4 and Resident 213) when changing bed linen and touching the urinary catheter bag (a receptacle that serves as a container or collector for urine as it leaves the body and passes through the catheter tube). B. remove gloves from the dispensing box before administering medication to Resident 25. C. Ensure placing correct isolation signage and following proper Personal Protective Equipment ([PPE]- equipment used to prevent or minimize exposure to hazards) requirement for Resident 62. These failures resulted in compromised infection control measures to prevent infectious disease among residents, staff, and visitors. Findings: a. During a review of Resident 4's Face Sheet (admission record), the Face Sheet indicated Resident 4 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement antibiotic stewardship program (measures used by the facility to ensure antibiotics [drug to treat infection] are used only when necessary and appropriate) for three of four sampled residents (Resident 12, 78, and 100) This failure had the potential to put Resident 12,78 and 100 at risk for antibiotic resistance (not effective to treat infection) and inappropriate use of antibiotic. Findings: 1.During a review of Resident 12's admission record, the admission Record indicated Resident 12 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including pneumonia (lung infection that causes the lungs to fill with fluid or pus leading to inflammation), difficulty walking, and localized edema (swelling caused by fluid building up in the body's tissues). During a review of Resident 12's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 7/5/2024, the MDS indicated Resident 12'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 ensure one of 24 sampled resident (Resident 90) was assessed for change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) or functional status which without immediate intervention, may result in complications or death) and physician informed when Resident 90 called 911 (a phone number used to contact emergency services) on [DATE], and [DATE]. This failure resulted in Resident 90 calling 911 and transferred to general acute care hospital (GACH) on [DATE] for abdominal pain and fecal impaction (large, hard mass of stool gets stuck in the rectum and cannot pass out). On [DATE] Resident 90 was hospitalized for stercoral colitis (a rare form of inflammatory colitis (inflammation in the colon, causing symptoms such as urgent, painful, runny, or bloody stools) that can develop as a result of chronic constipation (a problem with passing stool).…

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 one sampled resident (Resident 12) received continues oxygen therapy via nasal canula) a device that delivers extra oxygen through a tube and into your nose). This deficient practice had the potential to affect Resident 12's breathing and could cause desaturation (low blood oxygen concentration) from not receiving adequate amount of oxygen and a fire hazard. Findings: During a review of Resident 12's admission Order, the admission Record indicated Resident 12 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including type 2 diabetes mellitus (a condition in which the body fails to process glucose (sugar) correctly ), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), and schizoaffective disorder ( a mental health condition). During a review of Resident 12's Minimum Data Set (MDS- a comprehensive 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) were not used unnecessarily for one of three sampled residents (Resident 24) by failing to ensure a resident did not receive routine and as needed psychotropic drugs unless the medication was necessary to treat a diagnosed specific condition that was documented in the clinical record for Resident 24. This deficient practice had the potential to result in the use of unnecessary psychotropic drugs for Resident 24 and can lead to side effects and adverse consequences such as a decline in quality of life and functional capacity. Findings: During a review of Resident 24's admission Record, the admission Record indicated, Resident 24 was admitted to the facility on [DATE] with diagnosis including a mental state in which you are confused, disoriented, and not able to think or remember clearly), dementia (loss of memory, language, problem-solving and other thinking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that it was free of a medication error rate of five percent or greater as evidenced by the identification of four medication errors out of 28 opportunities for errors, to yield a facility medication error rate of 10.71 percent for three of three randomly selected residents (Resident 90, 310, and 81). This deficient practice had the potential for increased pain, side effects, poor wound healing, and stomach irritation. Findings: During a review of Resident 90's admission Record (Face sheet), the face sheet indicated Resident 90 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of but not limited to gastroenteritis (inflammation that spreads from the stomach into the intestines, causing pain vomiting and diarrhea), colitis (swelling of inflammation of the large intestines), and myocardial infarction (a heart attack that occurs when blood flow deceases or stops in one 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 three of three randomly selected residents (Resident 90, 310, and 81) by not administering Resident 90's lidocaine patch, by giving Resident 310 eyedrops in the wrong eye and by not giving Resident 81's calcium acetate with a meal. This deficient practice had the potential for Resident 90 experiencing increased pain, Resident 310 had the potential to develop side effects from receiving eyedrop in the wrong eye and Resident 81 experiencing stomach irritation from not receiving calcium acetate with meals. Findings: During a review of Resident 90's admission Record (Face sheet), the face sheet indicated Resident 90 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of but not limited to gastroenteritis (inflammation that spreads from the stomach into the intestines, causing pain vomiting and diarrhea), colitis (swelling of inflammation of the large intestines), pancreatic cyst…

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 24 sampled residents (Resident 87) food preferences were honored and documented. This failure resulted in Resident 87's not receiving food items of Resident 87's choice and preference. Findings: During a review of Resident 87s admission Record (Face Sheet), the Face Sheet indicated Resident 87 was admitted to the facility originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to diabetes mellitus (a group of diseases that affect how the body uses blood sugar), obesity, chronic kidney disease (the gradual loss of kidney function) and hyperlipidemia (high cholesterol). During a review of Resident 87's History and Physical (H&P), dated 7/18/2024, the H&P indicated Resident 87 had the capacity to understand and make decisions. During a review of Resident 87's MDS, dated [DATE], the MDS indicated, Resident 87 needed partial to moderate assistance with eating. The MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Social Service Policy & Procedure, Grievances which indicated that all facility grievance (complaint) investigations, should be initiated as soon as practicably possible, after the grievance is filed, for one of three sampled residents, Resident 1. This failure had the potential for an unaddressed and unresolved grievances and had the potential to affect the resident ' s quality of life. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of traumatic hemorrhage (a type of blood loss caused by blunt force) of left cerebrum (the largest part of the brain that is divided in two halves). A review of Resident 1 ' s History and Physical (H&P), dated 5/17/2024, indicated Resident 1 had the capacity (the ability to hold) to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (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 ensure call light was in reach for one out of three sampled Residents (Resident 2). This deficient practice had the potential to result in a delay in or in an inability for Resident 2 to obtain necessary care and services. Findings: During a review of Resident 2's admission records the admission record indicated Resident 2 was originally admitted on [DATE] and readmitted to the facility on [DATE] with diagnosis of type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) and hemiplegia and hemiparesis (muscle weakness or partial ability to move part of the body) affecting the left dominant side. During a review of Resident 2's history and physical (H&P) dated 10/24/23, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS- a comprehensive assessment and care planning tool) dated 2/20/2024, the MDS indicated Resident 2…

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 infection prevention and control program was implemented by conducting facility-wide response testing of Coronavirus-19 (COVID-19: a highly contagious infection, caused by a virus that can easily spread from person to person) for one of 4 sampled residents (Resident 4) who had closed contact of confirmed COVID-19 case. This deficient practice had the potential to prevent early diagnosis of COVID-19 and possible continued spread of COVID-19 for all staff and residents in the facility. Findings: During a record review of Resident 4's Face Sheet (admission record) indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including hypothyroidism (a condition where the thyroid gland does not release enough thyroid hormone into the bloodstream), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities, and hyperlipidemia (an elevated level of lipids-fats-in your blood). During 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 one (1) out of eight (8) sample residents (Resident 15 ) are treated with respect and dignity by failing to knock and request permission before entering resident`s room ( Resident 15). b. to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of her individuality for two (2) out of the eight (8) sampled residents (Resident 14 and 24). The facility staff was observed standing over the resident while assisting them during a meal. These deficient practices had the potential to affect resident's sense of self-worth and self-esteem. Findings: a. During a review of the Resident's 15 admission record (Face Sheet), the face sheet indicated Resident 15 was admitted to the facility on [DATE]. Resident 15 diagnoses included hemiplegia (paralysis of one side of the body), cerebral infarct (damage to the brain from interruption of its blood supply) morbid obesity (excessive body fat 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 interview and record review the facility failed to provide residents and or their responsible parties information on Advance Directives (an individual's wishes regarding medical treatment) for two of nine sampled residents (75 & 344). This deficient practice had the potential for violating Resident 75 and 344 choices for medical care. Findings: During a review of resident's medical records, the following information was missing: Resident 75 (admitted on [DATE]), did not have an advance directive or a signature declining information on how to get an advance directive. Resident 344 (readmitted on [DATE]), did not have an advance directive or a signature declining information on how to get an advance directive. During an interview on 11/04/21 at 8:56 a.m. with the Social Service Director (SS1), SS1 stated upon admission an advance directive is offered if the resident has the mental capacity to understand the advance directive. SS1 also stated if the resident does not have the mental capacity the resident'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 observations, interviews, and record reviews, the facility failed to: 1. Ensure that 11 multi dose medications had been discarded 90 days after date opened as per facility policy and procedure. This deficient practice had the potential for harm to residents due to the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages. 2. Ensure that six (6) insulin (medicine to lower blood sugar) for a resident had been discarded 28 days after date opened (Resident 1,15,19, and 29). This deficient practice had the potential for harm to residents due to the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages. Findings: 1. During a concurrent observation and interview on 11/3/2021, at 12:35 p.m., with Licensed Vocational Nurse (LVN) 3 during an inspection of facility medication cart, the following multi dose medications remains in the medication cart 90 days after date opened.…

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. ensure dietary staff performed proper hand hygiene during tray line. b. ensure the food thermometers were sanitized after removing from one food item and inserting into another food item. c. ensure all food items stored in the kitchen dry storage room were labeled and dated. This deficient practice placed the facility residents at risk for foodborne illness. Findings: a. During an observation on 11/2/21 at 12:00 p.m., in the kitchen during tray line, cook 1 removed his gloves and donned new gloves without washing his hands. During an observation on 11/2/21 at 12:05 p.m., in the kitchen during tray line, cook 1 used the same gloved hand to hold cooked chicken, and open the oven door. During an observation on 11/2/21 at 12:07 p.m., in the kitchen during tray line, cook 1 used the same gloves and knife to hold and cut cooked chicken and pork. Gloves were not changed, and knife was not cleaned. During an observation on 11/2/21 at 12:22 p.m., in the kitchen during tray line, cook 1 used gloved hand to open 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: After exit it was determined C and D were moved to F812 a. ensure staff properly used personal protective equipment (PPE) in yellow zone rooms. b. ensure staff performed proper hand hygiene while performing wound care treatment for Resident 45. c. facility failed to ensure licensed staff practiced hand hygiene after disinfecting a blood pressure cuff and stethoscope and after cleaning a blood glucose monitor (machine used to check blood sugar level) before donning (applying) gloves and touching one of one Resident's (17) fingers to perform a blood glucose test. d. facility failed to date and label one of one resident's (52) humidifier (used to add moisture to the oxygen) and oxygen tubing, per facility policy. These deficient practices had the potential to result in the cross contamination of residents' wounds, and the spread of diseases and infection. a. During an observation on 11/2/21 at 11:14 a.m., Certified Nursing Assistant (CNA) 2…

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 a pest-free environment and an effective pest control program to ensure the facility was free of fruit flies in the kitchen. This deficient practice had the potential to spread disease and cause food borne illness. Findings: During an observation on 11/2/2021, at 8:45 a.m., in the kitchen's dry storage room several (50-100) fruit flies were observed. Fruit flies were observed flying in the storage room, on the ceiling, on food containers, and on plastic storage bags. One fly was seen in the dishwashing area. During an interview on 11/2/2021 at 9:10 a.m., with the Dietary Supervisor (DS) 1, DS 1 stated staff check for flies whenever deliveries are received and when food is retrieved for the storage room. DS 1 stated if flies are seen in the kitchen the dietary staff must notify the maintenance supervisor who arrange the pest control visits. During an observation on 11/3/2021, at 8:10 a.m., in the kitchen, 2-3 fruit flies were seen in the dry storage area. During an observation on 11/4/2021, at 12:35…

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 three of six alert residents (Residents 37, 52, and 65) in the Resident Council Meeting were informed of their rights to receive information from State Long-Term Care Ombudsman (agencies acting as client advocates), and to be informed of how to contact the agencies and to communicate with them when needed. This deficient practice had a potential to negatively impact residents' rights to be informed. Findings: During a concurrent observation and interview on November 3, 2021 at 10:00 a.m., at the Resident Council Meeting in the dining room, the residents in attendance were asked regarding their rights in the facility and how to contact the Ombudsman's office. During the Group Meeting three of six residents who attended stated they did not know how to contact their local Ombudsman. Residents 57 stated there was a poster in the activity room with the Ombudsman contact information, but it has been taken down. All four walls in the dining room were observed, there were no poster containing the Ombudsman…

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 two of six alert residents (Resident 37 and 52) in the Resident Council Meeting were informed of their rights on how to file a grievance. This deficient practice had a potential to negatively impact residents' rights to be informed. Findings: During an interview on November 3, 2021 at 10:00 a.m., at the Resident Council Meeting in the dining room the residents in attendance were asked regarding their rights in the facility and how to file a grievance. During the Group Meeting two of six residents who attended stated they did not know how to file a grievance. Also, Two of six residents stated they worried if they complained about care someone would get back at them. During an interview on November 5, 2021 at 12:58 p.m., with the Social Service Director (SS1), SS1 stated she is responsible for overseeing the grievance process. If a resident communicates a concern she investigates and follow through with the appropriate department on a resolution. On admission the grievance process is discussed with residents and 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 observation, interview, and record review, the facility failed to ensure the residents have the right to be free from neglect, physical, verbal, and mental abuse for one of eight (8) sampled residents (Residents 57). This deficient practice had Resident 57 feeling attacked, humiliated, and degraded. Findings: During a review of the Resident's 57 admission record (Face Sheet), the face sheet indicated Resident 57 was admitted to the facility on [DATE]. Resident 57 diagnoses included hemiplegia (paralysis of one side of the body), cerebral infarct (damage to the brain from interruption of its blood supply) type 2 diabetes mellitus ( a condition in which the body fails to metabolize (process) glucose (sugar) correctly). During a review of Resident 57 's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/16/2021, the MDS indicated Resident 57 had no impairment in cognitive skills for daily decision making and no verbal behavior symptoms directed toward others. Resident 57…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a baseline individualized care plan to reflect the assessment and meet the immediate needs that included interventions to address activities, or regular room visits, and ongoing programs to support the resident in their choice of activities for one of one sampled resident (Resident 89). This deficient practice had the potential to decrease the physical and cognitive ability and hinder the emotional health of Resident 89. Findings: During a review of Resident 89's admission record indicated resident 89 was admitted on [DATE] with diagnoses that included subarachnoid hemorrhage (brain bleed), hypertension (high blood pressure) seizures (a sudden, uncontrolled electrical disturbance in the brain), atrial fibrillation (irregular heartbeat (arrhythmia) that can lead to blood clots), and weakness. During a review of Resident 89's Minimum Data Set (MDS-comprehensive screening tool) dated October 11, 2021, the MDS indicated Resident 89 was able to make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive and resident-centered care plan regarding Resident 's 16 continuous removal of her nasal cannula (device used to deliver supplemental oxygen) with the interdisciplinary team. This deficient practice had a potential to result in respiratory distress. Findings: During a review of the Resident's 16 admission record (Face Sheet), the face sheet indicated Resident 16 was admitted to the facility on [DATE]. Resident 16 diagnoses included acute respiratory failure with hypoxia (not enough oxygen in the blood), chronic obstructive pulmonary disease ([COPD] progressive disease that makes it hard to breath), dementia (loss of memory, language, problem-solving and other thinking abilities). During a review of Resident 16 's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 8/4/2021, the MDS indicated Resident 16 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 shower according to pre-determined schedule for one of two sampled residents (Resident 89), who was totally dependent on staff for ADL's. This deficient practice resulted in Resident 89 not receiving a shower for one month and had the potential to negatively impact Resident 89's self-esteem. Findings: During a review of Resident 89's admission record indicated resident 89 was admitted on [DATE] with diagnoses that included subarachnoid hemorrhage (brain bleed), hypertension (high blood pressure) seizures (a sudden, uncontrolled electrical disturbance in the brain), atrial fibrillation (irregular heartbeat (arrhythmia) that can lead to blood clots), and weakness During a review of Resident 89's Minimum Data Set (MDS-comprehensive screening tool) dated October 11, 2021, the MDS indicated Resident 89 was able to make herself understood and understand others usually. The resident is totally dependent on staff for Activities of 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 interviews and record review, the facility failed to develop a care plan with measurable goals and interventions to address the care and treatment for one of one residents (34) with dementia. This deficient practice had the potential to prevent Resident 34 from maintaining his/her highest practicable physical, mental, and psychosocial well-being. Findings: During a review of Resident 34's medical record, the record indicated the resident was originally admitted to the facility on [DATE]. Resident 34's diagnoses included: dementia (a progressive loss of brain function affecting memory, thinking, and behavior that interferes with daily functioning), a psychotic disorder (condition that affects the mind, where there has been some loss of contact with reality), and end stage renal failure (kidneys are damaged and cannot filter blood as they should). During a review of Resident 34's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/1/2021, the MDS indicated Resident 34'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 accurately document the time a controlled medication was removed from the narcotic drawer of the medication cart and failed to document immediately after the medication was given to one of one Residents (51). Licensed staff documented removing Vimpat (a schedule V controlled medication, which has a low potential for abuse relative to substances listed in Schedule IV and consist primarily of preparations containing limited quantities of certain narcotics; used to treat seizure disorders) from Resident 51's medication bubble pack in the controlled medication/narcotic drawer of the medication cart at 5 p.m. on 11/4/2021 but did not document in the electronic medical record until 8:17 p.m. on 11/4/2021. This deficient practice had the potential for loss of accountability, and the controls against narcotic drug loss, diversion, or theft. Findings: During a concurrent interview and record review on 11/5/2021 at 7 a.m., of station 2 medication green cart…

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 a medication error rate of five percent (5%) or greater. As evidenced by the identification of two out of 31 medication opportunities (observations during medication administration) for error, to yield a cumulative error rate of 6.45% for two of five residents (Residents 17 and 8) observed during the medication administration facility task. a. For Resident 17, the facility failed to follow the physician's order to administer Novolog Insulin Aspart (medication to treat abnormal blood sugar) before meals and did not administer the medication according to manufacturer's recommendations. b. For Resident 8, the facility failed to administer Metformin HCL (for diabetes [disease in which blood glucose/blood sugar levels are too high]) within the correct timeframe as ordered. These deficient practices had the potential to result in harm to Residents 17 and 8 by not administering medication as prescribed by the physician 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 observation, interview, and record review, the nursing staff failed to ensure a water pitcher was not provided at the bedside for one of one sampled resident (Resident 22) as ordered by the physician. This deficient practice had a potential for Resident 22 to choke and aspirate. Findings: During a review of the Resident's 22 admission record (Face Sheet), the face sheet indicated Resident 22 was admitted to the facility on [DATE]. Resident 22 diagnoses included Parkinson's ( a progressive brain disorder that affects movement ), dysphagia ( difficulty in swallowing ), severe protein-calorie malnutrition (not consuming enough protein and calories ). During a review of Resident 22 's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/02/2021, the MDS indicated Resident 22 had mild impairment in cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making and no verbal behavior symptoms directed toward others. Resident 16 extensive…

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.