North Park Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure three (3) of 46 sampled residents (Resident 2, Resident 7, and Resident 54) were kept free from the potential for injury when,1.A regular bed mattress was stored upright against the wall in Resident 2's room,2. Resident 54's order for floor pads next to both sides of the bed was not followed,3. room [ROOM NUMBER] had a metal strip, 6 inches in length and 1/4 inch in width, noted to be protruding at knee height out of the wall in a loop type fashion (coming out of the wall at top and back into the wall at the bottom) next to the bathroom door near Resident 7's bed.These failures placed Resident 2, Resident 7 and Resident 54 at increased risk for sustaining an injury.Findings: 1.A review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility with diagnoses which included encounter for surgical aftercare following surgery on the circulatory system, other abnormalities of gait and mobility, 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 accurately assess and obtain a physician's order for the safe use of bed rails (side rails, metal or plastic rails that can attached to the side of a bed) for 1 of 46 sampled residents (Resident 1) when, Resident 1's side rail screening tool (an assessment used to decide if bed rails are safe and needed for a resident) was completed incorrectly and Resident 1 did not have a physician's order to ensure side rails were clinically appropriate and safe.This failure placed Resident 1 at risk for entrapment (an event in which an individual is caught, trapped or entangled in the space) and could have led to serious injury.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side (weakness or paralysis on the left side of the body caused by bleeding in the brain not related to injury), unsteadiness on feet, cognitive communication deficit…

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 46 sampled residents (Resident 3) prescribed psychotropic drugs (drugs that affect a person's mind, emotions, and behavior) was free from unnecessary medications when Resident 3's as needed (PRN) order for alprazolam (used for short term relief of anxiety, by calming the nervous system) did not have a stop date.This failure had the potential to negatively affect Resident 3's health and well-being.Findings:A review of Resident 1's admission RECORD, indicated Resident 3 was admitted to the facility with diagnoses which included an anxiety disorder (persistent, excessive, and irrational fear or worry that interferes with daily life) and post-traumatic stress disorder (a mental health condition that's caused by an extremely stressful or terrifying event).During a concurrent interview and record review on 1/29/26 at 11:33 AM with the Director of Nursing (DON), Resident 3's Order Summary, dated 11/29/26, was reviewed. The DON confirmed Resident 3's order for alprazolam (a medication to reduce anxiety) was given 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 failed to ensure medications were stored and labeled to meet professional standards of practice for one of four medication carts when:1. One of four medication carts, Cart 4, contained three insulin pens (a medication dispensing device that help deliver medicine to lower blood sugar) and one insulin vial (a small container of medication) without open dates; and2. One of four medication carts, Cart 4, contained loose pills in the medication drawers.These failures had the potential to reduce the efficacy (effective of the medication) of the insulins and for bubble packs (single dose medication packets) to be short of resident needed medications, negatively impacting residents' health related to ineffective insulin from reduced potency and delayed medication administration related to undiscovered loss of medication from bubble packs.Findings:1.During a concurrent interview and observation of medication cart 4 on 1/27/26 at 2:20 PM, with licensed nurse licensed nurse (LN 10), the top left drawer of the medication 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 adequate supervision and a safe environment was provided to prevent an elopement (a resident leaves the facility or a secured area without staff permission or knowledge, putting them at severe risk of injury, getting lost, or death from exposure, traffic, or missed medical care) from occurring for one of two sampled residents (Resident 1) when, Resident 1, with severe cognitive impairment (a condition that affects a person's ability to think clearly, remember information, and make safe decisions) and known wandering risk, eloped from the facility during the night on 12/16/25 through an unlocked and unalarmed door located in the facilities laundry room.This failure resulted in Resident 1 leaving the facility without immediate staff knowledge of Resident 1's departure, Resident 1 remained missing for several hours during the night/early morning hours, Resident 1 entered a private residence approximately 0.4 miles from the facility,…

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

Based on interview and record review, the facility failed to ensure the transfer or discharge requirements were met for one sampled resident (Resident 1) when, the facility issued a 30-Day Notice of Discharge/Eviction to Resident 1 and Resident 1's Responsible Party (RP) for a denial of payment for services while an application for Medi-Cal (a public health insurance program which provides needed health care services for low-income people) was pending. This failure had the potential to negatively impact Resident 1's psychosocial well-being due to being given the 30-Day Notice of Discharge/Eviction. Findings: A review of Resident 1's social services note, dated 1/8/25, at 3:15 PM, indicated the facility was aware Resident 1's Medi-Cal application was in review. Review of Resident 1's social services note, dated 1/11/25, at 3:31 PM, indicated, Resident 1's RP acknowledged that Resident 1's Medi-Cal application was still under review and was not currently active. During an interview on 3/27/25, at 2:05 PM, with the Social Service Director (SSD), the SSD stated if a Medi-Cal application…

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

Based on observation, interview, and record review, the facility failed to store and distribute food in accordance with professional standards for food service and safety when: 1. Dietary Aide (DA) 1 was not wearing a hair net while in the kitchen, 2. Drinking glasses and food containers were wet nested (stacked wet promoting growth of bacteria), 3. Clean fruit cups, stored under the dishwasher, had water dripping onto them, 4. Expired yogurt was available for resident consumption, 5. Dishwasher water temperature was not in range, 6. Parts per million (PPM - amount of solution in water) of the dishwashing solution was below the accepted standard, 7. Two of three utensil drawers contained a moderate amount of dust and debris, 8. Two dented cans of corn were found in food storage; available for resident consumption, 9. Three fans in the kitchen, including the food prep area, contained a moderate amount of dust and debris; and, 10. There was a moderate amount of dust and debris on the counter above the stove top and on the oven. These failures had the potential of leading to food borne…

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

Based on interview, and record review, the facility failed to ensure the safe use of insulin (a high-risk injectable medication used to treat diabetes, a blood sugar disease) for two residents with diabetes (Resident 1 and Resident 596) out of a sample of 23 residents, when: 1. Resident 1's order for insulin did not include parameters with instruction when blood sugar was high, and ongoing high blood sugar levels were not treated or reported to the medical doctor; and, 2. Resident 596's diabetic medication and insulin use was not monitored by blood sugar measurement. These failures may have contributed to unsafe insulin and antidiabetic drug use and subsequent adverse events. Findings: 1. During a review of Resident 1's electronic medical record (EMR) titled, Diagnosis, the record indicated diagnoses of diabetes, heart, and kidney disease while under hospice care (comfort care) via primary care Medical Doctor (MD). During a review of Resident 1's EMR titled, Medication Administration Record, (or MAR, a document which lists medications and treatments administered based on doctor'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.

Based on interview, and record review, the facility failed to ensure an anti-anxiety medication was administered correctly for 1 of 23 sampled residents (Resident 61) when Resident 61 received a lower dose of anxiety medication 18 times in May of 2024 and once in September of 2024. This failure had the potential for Resident 61 to experience increased anxiety and emotional distress. Findings: Review of Resident 61's physician orders indicated, Lorazepam [or Ativan-an anxiety medication] oral tablet 1 mg [mg-milligram is a unit of measure]; Give 1 tablet by mouth every 6 hours for agitation with behaviors; Start Date: 4/29/24. During a comparative review of Resident 61's Controlled Drug Record (CDR, a paper record that keeps track of controlled medications and is used for accountability) and the MAR (a record of medications ordered and administered) for May 2024 and September 2024, the MAR documentation did not match the removal from the CDR when Ativan 0.5 mg was removed by nursing staff as follows: 5/3/24- two times Ativan 0.5mg given and documented as Ativan 1 mg given, 5/4/24-…

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 documented evidence of education for immunizations when four of four sampled residents' (Resident 14, Resident 17, Resident 20, and Resident 42) and one unsampled resident's (Resident 23) clinical records did not contain documented evidence of education for the COVID-19 vaccination. This failure had the potential for Resident 14, Resident 17, Resident 20, Resident 42, and Resident 23 to not be aware or informed of the benefits, risks, and potential side-effects of the COVID-19 vaccination prior to receiving or declining the vaccination. Findings: During a concurrent interview and record review on 10/4/24, at 8:40 AM, with the Infection Preventionist (IP), the IP acknowledged the box titled, Education Provided to Resident/Family, was not checked, and the IP confirmed the medical records for Resident 14, Resident 17, Resident 20, Resident 42, and Resident 23 did not contain documented evidence of education for the COVID-19 vaccinations risk and benefits to the above residents was provided. During an 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 failed to ensure a homelike environment was provided for 2 of 23 sampled residents (Resident 382 and Resident 3) when: 1. Resident 382's floor tiles were replaced with a rubber strip; and, 2. Resident 3 had broken blinds in her room. This failure had the potential to negatively impact Resident 382 and Resident 3's feelings of well-being in the facility. Findings: 1. During an interview on 10/2/24, at 3:59 PM, with Resident 382's Responsible Party (RP) 1, RP 1 stated she was afraid of tripping over the black part on the floor. RP 1 further stated that she had tripped over the black rubber strip a couple times in the past. RP 1 explained Resident 382's room was the only room on the unit that had the black rubber strip located right at the doorway entrance. RP 1 stated that she did not like the way the rubber strip looked and considered it to be a hazard. During concurrent observation and interview at 10/2/24, at 4:10 PM, with the Maintenance Director (DOM), the DOM confirmed no other doorways in the North Station had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop baseline care plans (captures key resident needs and must be developed within 48 hours of admission) for 2 of 23 sampled residents (Resident 545 and Resident 596) when: 1. A baseline care plan was not developed for Resident 545's right groin redness, left groin redness and perirectal (affecting the skin around the rectum) area redness within 48 hours of Resident 545's admission; and, 2. A diabetic (blood sugar disease) baseline care plan was not developed for Resident 596's plan of care to address management, treatment, and monitoring of her diagnosis of diabetes and multiple diabetic medications including insulin (a drug given as shot to treat blood sugar) and oral antidiabetic medications. These failures had the potential to result in Resident 545's identified skin issues to worsen and care needs not being met and resulted in a lack of healthcare information necessary to provide effective and person-centered care for Resident 596 which…

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 attending physician (AP) failed to provide orders for routine blood glucose (sugar) monitoring and provide adequate physician oversight and management for diabetic (blood sugar disease) care for one of twenty-three sampled residents (Resident 596) when, Resident 596 who was diabetic and received multiple medications to treat her diabetes did not have orders for routine blood sugar monitoring and did not have orders to manage complications associated with her anti-diabetic medication administration and diabetic diagnosis and care. This failure contributed to Resident 596 experiencing a fall related to low blood sugar, resulting in hospitalization and transfer to the intensive care unit (a department within a hospital for the critically ill), and subsequent adverse events including new onset seizures (unusual brain activity and involuntary movement). Findings: Review of Resident 596's admission RECORD, indicated Resident 596 was initially admitted to the facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices in medication carts (a mobile cart storing medications to be administered to residents) for a census of 93 when: 1. Medication Cart #4 at the facility's South station stored an outdated Lantus insulin Pen (blood sugar drug in a pen form) with an open date (the date the insulin was out of refrigerator and was started to be used) of [DATE] and the pharmacy label indicated discard 28 days after opening; and, 2. The treatment cart at the facility's North station stored an opened bottle of Sterile Sodium Chloride [a mixture of salt and water that is free from bacteria which is used to rinse sinuses, clean wounds, flush eyes and more] in the cart. These failed practices may result in residents receiving expired or unusable medications. Findings: 1. During a concurrent interview and inspection of medication cart #4 at facility's North Station, on [DATE], at 11:27 AM, accompanied by Licensed Nurse 5 (LN)…

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 documented evidence of education for immunizations (a process by which a person becomes protected against a disease through vaccination) when: 1. One of four sampled residents' (Resident 14) and one unsampled resident (Resident 23) records did not indicate education was provided for the Influenza (a common, sometimes deadly viral infection of the nose, throat and lungs, also called flu) vaccine; and, 2. One unsampled resident's (Resident 23) record did not indicate education was provided for the Pneumococcal Polysaccharide (PPSV 23 - for prevention of pneumonia; an infection that affects one or both lungs) vaccine. This failure had the potential for Resident 14 and Resident 23 to not be aware or informed of the benefits, risks, and potential side-effects of the vaccinations prior to receiving or declining the vaccination. Findings: 1. During a concurrent record review and interview on 10/4/24, at 8:40 AM, with the Infection Preventionist (IP), Resident 14's Influenza record, dated 9/29/23, was reviewed. The IP…

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 follow facility policy and standards of practice for medication administration for three of four sampled residents, (Resident 1, Resident 2, and Resident 3) when: 1. Licensed Nurse (LN) 2, failed to sign off medications at the time of administration for Resident 1, Resident 2, and Resident 3; 2. LN 6 administered morning medications late to Resident 1 on 3/7/24; and, 3. LN 4 left the medication cart unattended with medications on top. These failures had the potential for Resident 1, Resident 2, and Resident 3 to receive a duplication of their medications, for Resident 1 to experience health effects from late medications, and for a resident to inadvertently take medications left out on the cart. Findings: 1a. A review of the Medication Administration Audit Report (MAAR), dated 3/5/24 to 3/7/24, indicated medications due for Resident 1 on 3/6/24 at 7 AM, 8 AM, and 11 AM were signed off by LN 2 as follows: Prednisone (a steroid medication) and Rivaroxaban (a blood thinner medication) due at 7 AM were signed off…

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 readmit Resident 1 after he transferred to an acute care hospital and was ready to return to the facility. This failure resulted in a violation of Resident 1's right to return to the facility and had the potential to cause psychosocial harm due to not being able to return to the facility. Findings: Resident 1 was admitted to the facility in July of 2023 with diagnoses which included unspecified cirrhosis of the liver (a disorder in which the liver is scarred or permanently damaged) and chronic pain syndrome. During a telephone interview on 1/5/24, at 8:03 AM, the Ombudsman (OMB) stated there had been a conflict between Resident 1 and the facility. The OMB further stated the facility contacted law enforcement, and Resident 1 was sent to an acute care hospital. The OMB stated hospital staff talked to the Administrator (ADM) and the social services department and they refused to accept Resident 1 back. During a telephone interview on 1/5/24, at 11:10 AM,…

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 consistently schedule and document quarterly Interdisciplinary Team (IDT, care team consisting of different disciplines who assess and coordinate care), care plan conferences (a meeting which provides opportunities for the resident's and/or their representative, and each discipline to revise the residents plan of care) for three of three sampled residents (Resident 1, Resident 2, and Resident 3). These failures had the potential for unmet care needs for Resident 1, Resident 2, and Resident 3. Findings: 1. A review of Resident 1's admission RECORD, indicated she was admitted to the facility in September of 2021, with diagnoses which included unspecified dementia (condition characterized by memory disorders, personality changes and impaired reasoning), and psychotic disorder with delusions (a mental disorder characterized by disconnection from reality). A review of Resident 1's clinical document titled, Multidisciplinary Care Conference v.3, dated 9/29/22, indicated there was no entry in the following sections: .Meeting Date…

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 resident needs were met when: 1. Staff did not respond in a timely manner to calls for help for 5 of 13 sampled residents (Resident 2, Resident 3, Resident 5, Resident 7, and Resident 13); and, 2. The nursing call light system was not fully functional for rooms 28-53 (South Hall) and 45 of 47 residents were not provided an alternate audible method to call staff for help. These failures resulted in Resident 7 not receiving the assistance needed after she fell on 9/2/23 and 9/5/23, and Resident 2, Resident 3, Resident 5, and Resident 13 waiting up to three hours for assistance, with a potential to experience anxiety and feelings of neglect. Findings: 1a. A review of Resident 7's admission Record indicated Resident 7 was admitted to the facility with diagnoses which included a fracture of her right lower leg and unsteadiness on her feet. During an interview with Family Member (FM) 2, on 9/26/23, at 8:28 AM, FM 2 stated Resident 13…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe and hazard free environment when safe water temperatures were not maintained in five of five sampled resident restrooms, and two out of four resident shower rooms. This failure had the potential to cause physical harm to the residents in the facility. Findings: During a record review of the facility document titled, Water Temperature Checks: Test and log the hot water temperatures, dated February through July of 2023, indicated the following out of range water temperatures: 2/13/2023 RM (room) 1 126 F (Fahrenheit - a unit of measure), RM [ROOM NUMBER] 122 F, RM [ROOM NUMBER] 128 F, RM [ROOM NUMBER] 130 F; 3/31/2023 Front Bathroom [ROOM NUMBER] F, RM [ROOM NUMBER] 122 F, RM [ROOM NUMBER] 118 F, RM [ROOM NUMBER] 124 F, RM [ROOM NUMBER] 124 F; 4/7/2023 RM [ROOM NUMBER] 118 F, RM [ROOM NUMBER] 119 F, RM [ROOM NUMBER] 122 F, Front Bathroom [ROOM NUMBER] F; 4/10/2023 Front Bathroom [ROOM NUMBER] F, RM [ROOM NUMBER] 122 F;…

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 respiratory care provided was consistent with professional standards of practice for 2 of 12 residents receiving respiratory treatment (Resident 22 and Resident 65) when: 1. Oxygen therapy was provided without a physician order for Resident 22; and, 2. Resident 65's oxygen order was not followed. These failures placed Resident 22 and Resident 65 at risk for respiratory distress and inadequate treatment. Findings: 1. A review of Resident 22's admission Record indicated Resident 22 was admitted to the facility in 2021 with diagnoses which included chronic respiratory failure (when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). During a review of Resident 22's oxygen care plan, dated 8/15/23, the care plan indicated, Interventions .Administered [sic] oxygen as ordered . During a concurrent observation and interview on 8/30/23, at 2:31 p.m., with licensed nurse (LN) 6 in Resident 22's room, Resident 22 was observed lying in bed and receiving oxygen via…

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 doctor's progress notes (doctor's note about resident progress, care, and medical issues) and/or History and Physical (or H&P - the most formal and complete assessment of the resident's medical problems) were documented and available in the medical records for 3 of 25 sampled residents (Resident 23, Resident 27, and Resident 45). These failed practices may contribute to unsafe care and poor communication, or coordination of care among staff members caring for the residents. Findings: 1. A review of Resident 23's electronic medical record indicated Resident 23 was re-admitted to the facility on [DATE], with multiple medical diagnoses and medications to treat them. During a concurrent interview and review of Resident 23's medical record, both electronic and paper version, on 8/30/23, at 8:48 AM, Licensed Nurse (LN) 6 acknowledged the physician's progress notes were not available in the medical record both electronically and in the paper chart. LN 6…

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

Based on observation, interview, and record review, the facility failed to ensure safe food production when: 1. Open food packages (1 bag of bread rolls, and a box of fried chicken breast patties) were not labeled with an open date; and, 2. An expired food product (an open bag of carrot cake mix) was not removed. These failures had the potential to expose 96 residents of a census of 97 to food borne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: On 8/29/23, at 8:47 a.m., during an initial tour of the kitchen accompanied by the [NAME] (CK), the following findings were observed: 1. a. An opened clear plastic bag containing approximately 20 bread rolls was not labeled with an open date. The CK stated the bag should have been labeled with an open date. 1b. An opened box containing approximately 20 fried chicken breast patties was not labeled with an open date. The CK further stated it should have been labeled with an open date once the box was opened by kitchen staff. The CK explained the risk was not knowing how old the food was. 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 maintain its Antibiotic Stewardship Program (ASP- efforts to measure and improve how antibiotics prescribed by doctors and used by patients with goal of reducing inappropriate antibiotic use) when the facility did not ensure appropriate monitoring and use of antibiotics for 3 of 17 residents who were on antibiotics (Resident 27, Resident 40, and Resident 69) when: 1. Resident 27 was prescribed two antimicrobials (drugs that treat infections caused by microbes like bacteria, yeast, or mold) for ongoing use without any documentation of continued use and re-assessment. 2. Resident 40 was prescribed an antibiotic for ongoing use without any documentation of continued use or re-assessment. 3. Resident 69 was prescribed an antibiotic for ongoing use to which the bacteria was resistant. These failed practices could pose unsafe antimicrobial drug use and contribute to resistance patterns (resistance happens when germs like bacteria or yeast develop the ability…

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 call light was within reach for 1 of 25 sampled residents (Resident 64). This failure had the potential to result in Resident 64 being unable to ask for needed assistance and to negatively impact his physical and psychosocial well-being. Findings: A review of Resident 64's admission Record indicated Resident 64 was admitted to the facility with multiple diagnoses which included Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills, and to carry out the simplest tasks), acute respiratory failure, anxiety, major depressive disorder, heart failure and presence of cardiac pacemaker (a medical device to stimulate heart muscles to ensure the heart is beating). During a concurrent observation and interview on 8/29/23, at 12:06 p.m., with Licensed Nurse (LN) 1, Resident 64's's door was closed. Upon entry into the room, Resident 64 was sleeping in bed with no call light in reach. LN 1 looked for the call light and found it inside Resident 64's dresser drawer, and stated the call…

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

Based on observation, interview and record review, the facility failed to ensure 1 of 25 sampled resident's (Resident 396) right to self-determination was respected when, Resident 396 and Family Member (FM) 1 requested a female Certified Nursing Assistant (CNA) as a care giver and staff did not honor Resident 396's wishes. This failure had the potential to negatively impact Resident 396's psychosocial well-being. Findings: Review of Resident 396's admission Record indicated Resident 396 was admitted to the facility in 2023. Review of Resident 396's Minimum Data Set (MDS- an assessment tool used to guide resident care) section G, dated 8/25/23, indicated, Resident 396 needed, . physical assist in dressing, toilet use and personal hygiene, including total dependence for bathing. During an interview on 8/29/23, at 3:07 p.m., Family Member (FM) 1 indicated Resident 396 preferred a female CNA as her care giver. FM 1 stated he had communicated Resident 396's preference to the Case Manager (CM). FM 1 further stated Resident 396's assigned CNA was a male on 8/29/23. During a concurrent…

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 1 of 25 sampled residents (Resident 16), had a care plan (a formal process that correctly identifies existing needs and recognizes potential needs or risks) developed to address Resident 16's arteriovenous fistula (AV- connection between an artery and a vein used as an access site for dialysis, a procedure to remove wastes and excess fluids from the body when the kidneys stop working properly.) This failure had the potential for Resident 16's fistula to be unattended and could possibly lead to complications and risk for infection. Findings: A review of Resident 16's admission Record indicated Resident 16 was admitted to the facility in 2022 with diagnoses which included end stage renal disease (a medical condition when the kidneys are unable to filter waste products from the blood) and dependence on dialysis. According to Resident 16's Minimum Data Set (MDS- an assessment tool), dated 8/7/23, indicated, Resident 16 required dialysis. During a concurrent interview and record review on 9/1/23, at 12:41 p.m., 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.

Based on observation, interview, and record review, the facility failed to ensure safe monitoring practices for high-risk medication (drugs with potential to cause harm without monitoring) use in 2 out of 25 sampled residents (Resident 60 and Resident 390) when: 1. Resident 60 was prescribed a high-risk blood thinner medication called apixaban (or Eliquis, a blood thinner medication that could cause bleeding) without side effect monitoring and assessment; and, 2. Resident 390 was prescribed a high-risk medication called digoxin (used to control heart rate and rhythm) without any monitoring parameter or care planning. These failures had the potential to result in unsafe medication use and adverse consequences. Findings: 1. Review of Resident 60's electronic medical record, Progress Notes: Nursing, dated 8/1/23, indicated, [Resident 60] was admitted [to the facility] on 7/31/23 for .Therapy .and nursing services for medication management. The note further indicated Resident 60 was receiving an injectable (shot into the skin) form of blood thinner called Enoxaparin (a blood thinner…

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 residents receiving dialysis (procedure done by a trained professional to remove wastes and excess fluids from the body when the kidneys stop working properly) received quality care and services consistent with professional standards of practice for one of three residents (Resident 16), when Resident 16's arteriovenous fistula (AV- connection between an artery and a vein used as an access site for dialysis) was not assessed and monitored regularly for bruit (a sound heard through a stethoscope) and/or thrill (vibrations felt by touch). This failure increased the potential risk for delayed detection, reporting, and/or management of complications from the dialysis access site for Resident 16. Findings: A review of Resident 16's admission Record indicated Resident 16 was admitted to the facility in 2022 with diagnoses which included end stage renal disease (a medical condition when the kidneys are unable to filter waste products from the blood) and dependence on dialysis. According to the 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.

Based on interview and record review the facility failed to ensure safe disposal and destruction of the non-narcotic (not an opioid drug) prescription medications for a census of 97. This failed practice could result in drug diversion or unsafe and unlawful use of prescription medications. Findings: During an inspection of the facility's medication room in the South station on 8/29/23, at 9:50 a.m., accompanied by the Case Manager (CM), the logbook titled, Medication Disposition Record/Pass Log, with date range of 3/25/23 and 8/27/23, indicated disposition of the medications was not witnessed by a second licensed staff. The column on the log sheet, titled as Witnessed by ., was not marked by a second signature. CM confirmed the markings on the logbook. In an interview with Director of Nursing (DON) on 8/31/23, at 9: 39 a.m., the DON stated the nursing staff were assigned to destroy unused or discontinued prescription medications on a regular basis. The DON stated the destructions were performed by one licensed nurse. The DON further stated the facility's policy allowed one nurse 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 facility failed to ensure 1 resident's in a sample of 25 (Resident 140) nutritional needs were met when the facility did not provide a mechanically soft diet (food chopped for easier chewing and swallowing). This failure had the potential for Resident 140 to aspirate (choke on food) her food. Findings: A review of Resident 140's admission Record, indicated Resident 140 was admitted to the facility with diagnoses which included, pneumonia (respiratory infection) and chronic kidney disease (a gradual loss of kidney function over time). During a concurrent observation and interview with Resident 140 on 8/31/23, at 8:03 AM, Resident 140's meal tray arrived. The tray consisted of two sausages with gravy, french toast with no syrup on it, an over easy egg, and hot cereal. Resident 140 stated she did not like the breakfast. The tray card indicated the meal should be of mechanical soft consistency. The food was not of a mechanical soft consistency. During an interview with certified nursing assistant (CNA) 1, on 8/31/23, at 8:40 AM,…

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

Based on observation, interview, and record review, the facility failed to ensure 1 resident in a sample of 25 (Resident 140) food preferences were honored when Resident 140's food preferences were not listed on her tray card (a card that displays the resident's name, food preferences, likes and dislikes, and meal type and consistency). This failure had the potential for Resident 140 to eat less of her meals and result in weight loss. Findings: A review of Resident 140's admission Record, indicated Resident 140 was admitted to the facility with diagnoses which included, pneumonia (respiratory infection) and chronic kidney disease (a gradual loss of kidney function over time). During an interview on 8/29/23, at 2:52 PM, Resident 140 stated her food preferences were not being honored. Resident 140 further stated she received food she doesn't like, such as gravy and hot cereals. Resident 140 stated she had put her food likes and dislikes on the tray card but was still receiving food she did not like. During a follow up observation and interview with Resident 140 on 8/31/23, at 8:03 AM,…

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 its infection control program when licensed nurse (LN) 1 did not don(put on) personal protective equipment (PPE - worn to protect against bacteria and viruses) correctly prior to entering the room of a COVID-19 positive resident. This failure had the potential for LN 1 to become infected with COVID 19 and transmitting COVID 19 to other residents in her care. Findings: During an observation on 9/1/23, at 9:46 AM, a staff member donned PPE to enter a resident room, including an N95 respirator (a respiratory protective device designed to achieve a very close facial fit and efficient filtration of airborne particles). Signage on the door indicated, RED ZONE [a room designated to isolate a resident with COVID-19]. During a concurrent observation and interview with licensed nurse (LN) 1, on 9/1/23, at 9:48 AM, LN 1 exited the room. LN 1 had a regular face mask under the N95. LN 1 confirmed she was wearing the N95 respirator over a regular face mask. LN 1 stated she should not be wearing an N95 respirator…

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.