Tracy Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure quality of care and services were provided to one of three sampled residents (Resident 1) when cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating) was not attempted by licensed staff when Resident 1 was found unresponsive on [DATE].This failure resulted in the wishes for Resident 1's Representative/ Decisionmaker (RR) not being honored and also potentially contributed to the death of Resident 1.A review of Resident 1's admission RECORD, dated [DATE], indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD- a group of lung diseases that cause persistent airflow obstruction and breathing problems that can significantly impact quality of life and life expectancy), encounter for palliative care (medical services where a patient receives care and support related to a serious or life-limiting illness), dementia…

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 preferences for end of life or emergency care would be honored for 3 of 22 sampled residents (Residents 12, 43, 49) when, 1. The facility failed to determine upon admission whether Resident 43 and Resident 49 had an Advance Directive (specific instructions about one's own health care) and, if not, determine whether they wished to formulate an Advance Directive; and, 2. The facility failed to ensure a copy of Resident 12's Advance Directive was available at the facility. These failures could have resulted in the residents' end of life wishes not being honored. Findings: 1a. During a review of Resident 43's clinical record titled, admission Record (a document that contained the resident's demographic information), the record indicated Resident 43's diagnosis included type 2 diabetes (the body's inability to control blood sugar), and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). A review of Resident…

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

Based on interview, and record review, the facility did not ensure correct medications were administered for 1 of 22 sampled residents (Resident 22) when Resident 22 was admitted with the wrong discharging documents from the acute hospital and the error was not identified for three days after admission. This failure placed Resident 22 at risk for complications related to medications received which were not intended for her. and complications related to medications she should have received, but did not for three days. Findings: The Department received a report from the facility and a complaint regarding Resident 22's interfacility transfer (IFT) documents (IFT- a communication tool when transferring a patient to another facility which contains pertinent information regarding the patient's care received from the discharging facility and to continue care at the admitting facility) from the acute hospital indicated a different name and did not reflect the correct information at time of admission. This error caused Resident 22 to receive medications that were not prescribed for her until…

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 meet the needs of 1 of 22 sampled residents (Resident 12) when the facility did not adequately follow up on the resident's request for a prosthetic (artificial) leg. This failure had the potential to result in loss of independence, dignity, and decreased quality of life. Findings: During a review of Resident 12's clinical record titled, admission Record (a document that contained the resident's demographic information), indicated Resident 12's diagnosis included Type 2 diabetes (inability to control blood sugar) and the absence of left leg above the knee. During a concurrent observation and interview on 8/27/24, at 10:34 a.m., Resident 12 was observed in her bed with her wheelchair at the bedside. Resident 12 had her left leg amputated (a limb that had been surgically removed). Resident 12 stated she had been waiting for a year for her prosthetic leg. Resident 12 stated she was willing to put in the work with Physical Therapy to get stronger in order to walk. Resident 12 stated she would have liked 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.

Based on observation, interview, and record review, the facility failed to ensure a homelike environment was provided for 1 of 22 sampled residents (Resident 55), when Resident 55 did not have enough room to store personal belongings. This deficient practice did not ensure a homelike environment that encouraged the use of personal belongings to the extent possible. Findings: Review of Resident 55's admission record indicated Resident 55 had been admitted to the facility in July of 2024. During a concurrent observation and interview on 8/27/24 at 12:16 PM with a family member (FM)1, FM 1 stated he was concerned about space in the room. FM1 showed the narrow closet space dedicated to Resident 55 in bed A. FM1 then stated he felt frustrated due to lack of space for the resident's personal belongings and pointed to the drawers. FM1 indicated he was unable to use the drawers dedicated to bed A, because a previous resident's name was labeled on all of bed A's drawers. FM1 further stated that he did not feel comfortable touching the belongings that were still in the drawers. 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.

Based on interview, and record review, the facility failed to develop and implement a resident specific care plan (provides direction on the type of nursing care the resident may need based on their health, medication, behavioral, and psychosocial needs) for 1 of 22 sampled residents (Resident 317) when Resident 317 did not have a care plan developed for catheter care. This failure had the potential for care needs not being met for Resident 317. Findings: A review of Resident 317's admission RECORD, indicated Resident 317 was admitted to the facility in the middle of 2024 with diagnoses which included urinary tract infection and artificial openings of urinary tract status. During a review of Resident 317's Minimum Data Set, (MDS-an assessment tool) dated 8/27/24, the MDS indicated Resident 317 had an indwelling catheter (a medical device that drains urine from the bladder to a drainage bag). A review of Resident 317's Order Summary Report, indicated, .Catheter Care for Indwelling catheter every shift for catheter care cleanse area every shift monitor for redness, irritation,…

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 care and services for activities of daily living (ADLs) for 1 of 22 sampled residents (Resident 22) when Resident 22 had no documented evidence a shower was given from 8/6/24 through 8/15/24. This failure had the potential to result in poor hygiene and decreased psychosocial well-being for Resident 22. Findings: A review of Resident 22's admission RECORD, indicated Resident 22 was admitted to the facility in the middle of 2024 with diagnoses which included presence of left artificial hip joint, diabetes mellitus (too much sugar in the blood), and heart disease. During a phone interview on 8/29/24, at 10:16 a.m. with Resident 22's Family Member (FM) 3, FM 3 stated Resident 22's shower schedule was Tuesdays and Saturdays. FM 3 stated Resident 22 did not receive a shower on a Tuesday. During a concurrent interview and record review on 8/30/24, at 8:09 a.m. with the Director of Staff Development (DSD), Resident 22's Shower Skin Checks Sheets were reviewed. The DSD confirmed Resident 22's shower days were Tuesdays and…

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

Based on interview, and record review, the facility did not ensure correct medications were administered and correct plan of care was followed for 1 of 22 sampled residents (Resident 22) when Resident 22 was admitted with wrong discharging documents from the acute hospital and the error was not identified for 3 days after admission. This failure placed Resident 22 to not receive the necessary care and services at time of admission and three days thereafter. Findings: The Department received a report from the facility and a complaint regarding Resident 22's interfacility transfer (IFT) documents (IFT-it is a communication tool when transferring a patient to another facility which contains pertinent information regarding the patient's care received from the discharging facility and to continue care at the admitting facility) from the acute hospital indicated a different name and did not reflect the correct information at time of admission. This error caused Resident 22 to receive medications that were not prescribed for her and care that was not intended for her until it was…

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

Based on interview and record review, the facility failed to ensure adequate supervision was provided to prevent accidents and hazards for 1 of 22 sampled residents (Resident 62) when the facility did not implement Resident 62's care planned intervention of a wheelchair alarm, and staff did not complete bed alarm checks during the night shift on 7/3/24. This failure could have been a factor in staff not being aware of Resident 62's fall outside, and had the potential increased wandering behavior would not be identified. Findings: A review of Resident 62's admission Record indicated Resident 62 was admitted to the facility in Spring of 2024 with diagnoses including benign prostatic hyperplasia (a condition in men in which the prostate gland [a gland in the male reproductive system] is enlarged), surgical aftercare following surgery on the prostate, history of falling, anxiety disorder (a nervous condition characterized by a state of excessive uneasiness, apprehension, and panic attacks that interfere with activities of daily living), major depressive disorder (a persistent feeling 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.

Based on observation, interview and record review, the facility failed to ensure one of two residents (Resident 35) who received parenteral (delivery of medication through a vein) medication was provided services consistent with professional standards of practice when: 1. Resident 35's peripheral IV saline lock (a thin flexible tube placed in a vein in the hand or arm used to give medication and fluids) dressing was not dated; 2. Resident 35 did not have a care plan developed for the IV saline lock; 3. IV site care and flushing for Resident 35's IV saline lock was not documented in the medical record; and, 4. Resident 35's IV saline lock was left in place for eight days. These failures had the potential to increase the risk of infection for Resident 35 and further compromise her health and well-being. Findings: A review of Resident 35's admission Record indicated Resident 35 was admitted to the facility in Spring 2024. Resident 35's admission Record indicated Resident 35's admitting diagnoses included wedge compression fracture of second lumbar vertebra (a broken bone in the lower…

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 controlled medications (highly addictive and regulated medications) for 1 of 22 sampled residents (deceased Resident 58) were removed from the medication cart and the nurses did not count Resident 58's controlled medications at shift change. These failures could have resulted in medication being given to the wrong resident and/or drug diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled medications. Findings: A review of Resident 58's Electronic Health Record (EHR) indicated Resident 58 died on [DATE]. During a concurrent observation and interview on [DATE], at 3:17 p.m., with Licensed Nurse (LN) 1 and LN 6, the LNs counted the controlled medications for medication Cart # A (day shift)/Cart # C (PM shift). LN 1 and LN 6 acknowelged they forgot to count the controlled medications for Resident 58. LN 1 verified she should have counted Resident…

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

Based on observation, interview, and record review, the facility failed to ensure 1 of 22 sampled residents (Resident 30) received recommended dental services when Resident 30 was not provided the dental treatment recommendation of a full mouth x-ray (a set of pictures that provides images of teeth, gums, and jaw bones) for a broken tooth which was identified on 4/22/24. This failure had the potential to result in health complications for Resident 30 including increased discomfort, infection, problems chewing food, and weight loss. Findings: During a concurrent observation and interview on 8/27/24 at 10:01 AM, Resident 30 stated she needed dental care. Resident 30 reported she had dental pain in her teeth for about two months and no one had come to look at her teeth. Resident 30 stated she had told multiple staff members but did not remember which staff members. Resident 30 opened her mouth and pointed inward to her upper and lower teeth, stating she had pain. During a second interview on 8/28/24 at 2:53 PM, Resident 30 stated, I feel frustrated like I am not being heard and 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.

Based on interview, and record review, the facility failed to ensure copies of evaluations were in the resident's medical records for 1 of 22 sampled residents (Resident 12), when the facility did not have access to copies of Resident 12's evaluations for a prosthetic (artificial) leg. This failure had the potential for medical providers not to have reviewed the recommendations regarding acquiring a prosthetic leg for Resident 12. Findings: During a review of Resident 12's clinical record titled, admission Record (a document that contained the resident's demographic information), the record indicated Resident 12's diagnosis included Type 2 diabetes (inability to control blood sugar) and absence of left leg above the knee. During a concurrent observation and interview on 8/27/24, at 10:34 a.m., Resident 12 was observed in her bed with her wheelchair at the bedside. Resident 12 had her left leg amputated. Resident 12 stated she had been waiting for a year for her prosthetic leg. Resident 12 stated she was willing to put in the work with Physical Therapy to get stronger and walk.…

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, interviews and record reviews, the facility failed to maintain infection control measures when: 1. Certified Nurse Assistant (CNA) 10 entered the room of a resident on Contact Isolation Precautions (a type of transmission based precautions intended to prevent the spread of multi-drug resistant organisms [MDRO, germs that are resistant to three or more drugs that kill infection] and other germs that cause infections that are spread by direct or indirect contact with the resident or the resident's environment) without the appropriate personal protective equipment (PPE, gowns, gloves, eye protection, face masks or respirators used to prevent the spread of germs), then exited the room without performing hand hygiene (washing hands with soap and water or using alcohol-based rubs [hand sanitizers] to keep hands clean); 2. CNA 7 distributed clean water pitchers to residents on a cart with dirty water pitchers, a dirty cup, and a resident food tray with partially eaten food; and 3. Resident 46's urinary catheter bag (a bag that collects urine from a tube inserted into…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure resident bedrooms measured at least 80 square feet per resident in seven shared rooms. This failure had the potential to limit the personal belongings of each resident and compromise their ability to move freely in their rooms. Findings: During an interview on 8/27/24, at 11:00 a.m., with the Administrator (ADM), the following rooms did not meet the minimum space requirement for each resident: Room: Occupancy Room Size 1 3 243.5 x 136.5 (231 square feet (ft 2) 3 3 244.5 x 135 (229 ft 2) 5 3 243.5 x 134 (230 ft 2) 6 3 244.3 x 136.5 (232 ft2) 8 3 244 x 136.5 (231 ft 2) 10 3 243.5 x 140.5 (238 ft2) 11 3 243.5 x 135.5 (229 ft2) During an interview on 8/28/24, at 8:51 a.m., with the Licensed Nurse (LN 1), LN 1 stated she had enough room to do her job safely in rooms [ROOM NUMBERS]. LN 1 stated she has not had a resident complain to her about the room size. During a concurrent observation and interview on 8/28/24, at 8:53 a.m., with Resident 47, Resident…

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

Based on interview and record review, the facility failed to provide notice of a facility-initiated discharge to the appropriate parties for one of two sampled residents (Resident 1) when, Resident 1 was provided a notice of discharge for failure to pay on 1/3/24 and the notice was not sent to a representative of the Office of the State Long-Term Care (LTC) Ombudsman (a patient rights advocate). This failure resulted in the State LTC Ombudsman being uninformed of the discharge decision, removed the opportunity for the State LTC Ombudsman to advocate on Resident 1's behalf, and removed the State LTC Ombudsman awareness of the facility's activities related to discharges. Findings: During an interview on 2/5/24, at 4:24 p.m., the Ombudsman stated Resident 1 informed her the facility provided Resident 1 a thirty-day notice of discharge. The Ombudsman stated the State LTC Ombudsman office had not received a thirty-day notice of discharge from the facility for Resident 1. During a concurrent interview and record review on 2/6/24, at 3:02 p.m., a document titled STATE OF CALIFORNIA OFFICE…

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 notice of a facility-initiated discharge (a resident is given 30 days notice to find another place to live) to the appropriate parties for Resident 1 when, Resident 1's representative (RR, a designated person to make decisions for another person) was provided a notice of discharge on [DATE] and the notice was not sent to a representative of the Office of the State Long-Term Care (LTC) Ombudsman (a resident rights advocator) at the same time. This failure had the potential for the State LTC Ombudsman not being aware of Resident 1's facility initiated transfer/discharge and potentially prevented the opportunity for the State LTC Ombudsman to advocate for resident 1's rights. Findings: During an interview on 2/14/24, at 9 a.m., the Ombudsman stated the State LTC Ombudsman office had not received a notice of discharge from the facility for Resident 1. Review of Resident 1's Social Services Note dated 11/20/23, indicated, The resident's [Resident 1]…

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

Based on observation, interview, and record review, the facility failed to ensure needs of the residents were accommodated for two of three sampled residents (Resident 1 and Resident 3), when call lights were not within reach for Resident 1 and Resident 3. This failure had the potential to result in Resident 1 and Resident 3 being unable to ask for needed assistance and placed them at risk for falling. Findings: During a concurrent observation and interview on 11/30/23, at 1:45 p.m., with Resident 1, in Resident 1's room, Resident 1 looked for his call light within his bed linens. Resident 1 stated he could not find the call light and wanted to get out of bed. Resident 1 further stated he needed to yell for help to get a nurse to come to the room. Resident 1 explained the facility staff instructed him to call for assistance to get in and out of bed. The call light for Resident 1 was observed hanging against the wall, looped over the section of the cord where the call light system was attached to the wall. Resident 1 was not able to reach the call light while in bed. 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 ensure infection control measures were used to prevent the spread of germs when: 1. Facility staff and one visitor did not wear protective equipment (such as gowns and gloves) prior to entering the room of a Clostridium-Difficile (C-Diff- a bacteria that causes inflammation of the colon and can be transmitted from person to person by spores) positive resident (Resident 5) and did not perform hand hygiene. 2. Cleaning of a Glucometer (a device for measuring the concentration of sugar in the blood) was not completed after use. 3. Recommended cleaning wipes were not used to clean Resident 5's room. These failures had the potential to spread germs to residents, staff, and visitors within the facility. Findings: During an observation, on 9/21/23, at 6:22 a.m., room [ROOM NUMBER] was observed to have signage for contact precautions (precautions intended to prevent transmission of infectious agents which are spread by direct or indirect contact…

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

Based on observation, interview, and record review, the facility failed to provide restorative (RNA-nursing intervention to increase or maintain resident's mobility and to prevent further decline in mobility) treatment and services to 2 of 19 sampled residents (Resident 13, and Resident 25) when: 1. No interventions were used to address Resident 13's left hand contracture (when muscles, tendons, joints, or other tissues tighten or shorten causing a deformity and loss of movement); and, 2. Range of motion (ROM, the degree of movement that occurs at a given joint during an exercise) exercises were not provided as ordered for Resident 13 and Resident 25. These failures placed Resident 13 and Resident 25 at risk for not maintaining their highest practicable level of physical well-being. Findings: 1. A review of Resident 13's admission Record indicated Resident 13 was admitted to the facility in 2023 with diagnoses which included hemiplegia (paralysis) and hemiparesis (muscle weakness on one side of the body) affecting the left side, cerebrovascular disease (a group of disorders 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.

Based on interview and record review, the facility failed to ensure reconciliation and accountability of controlled medications (medications with high potential for abuse or addiction) and accurate medication administration when, 1. A random controlled medication use audit for Resident 25 did not reconcile. The medication was signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but was not documented on the Medication Administration Record (MAR, a legal document used to record medications given to the residents) on multiple occasions to indicate it was given to Resident 25; and, 2. Resident 38's medications were left unattended and unsupervised on her bedside table. These failures had the potential for diversion and/or misuse of controlled medications in the facility and possible under or over medicating the residents, and had the potential to result in harm to Resident 38 and to other residents who could gain access to her medications. Findings: 1. A review of Resident 25's clinical record indicated Resident 25…

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 medications and supplies were clearly labeled, safely handled, properly stored, and disposed of in accordance with manufacturer guidelines and accepted professional standards for a census of 55 when: 1. An opened bottle of Lorazepam (a medication used to treat anxiety and sleeping problems with high potential for abuse or addiction) was stored in the medication room refrigerator without an opened-date label and initials; 2. A bubble pack (a form of packaging where an individual pushes individually sealed tablets through the foil to remove the medication) of Divalproex Sodium (a medication used to treat certain types of seizures/epilepsy) was stored in medication cart C with no hazardous drug label; 3. An opened foil tray of Breo Ellipta inhalation powder (a medication used to prevent and control symptoms of asthma for better breathing), an opened Spiriva Respimat inhalation spray (a maintenance medication used as treatment for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure shared resident bedrooms measured at least 80 square feet (sq. ft.) per resident in a total of 7 resident rooms. This failure had the potential to result in a lack of sufficient space for the provision of resident care, to maintain privacy, and to allow for residents' personal property. Findings: During a concurrent observation and interview on 8/17/23, at 1:56 PM, the maintenance supervisor (MS) measured rooms 1, 3, 5, 6, 8, 10 and 11 with a measuring tape. The administrator (ADM) and the MS confirmed the room measurements. The ADM provided the following documented room measurements for the resident rooms which did not meet the minimum space requirement of 80 sq. ft. per resident in shared bedrooms: Room Occupancy Required/actual sq. ft. Sq. Ft. per resident 1 3 residents 240/231 sq. ft. 77 3 3 residents 240/229 sq. ft. 76.3 5 3 residents 240/230 sq. ft. 76.66 6 3 residents 240/232 sq. ft. 77.3 8 3 residents 240/231 sq. ft. 77 10…

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, record, and facility policy review, the facility failed to ensure 2 of 19 sampled residents (Resident 49 and Resident 34), had a care plan (a formal process which identifies existing needs and recognizes potential needs or risks) developed to address: 1. Resident 49's pressure ulcer (PU-pressure related damage to the skin and underlying tissue) to left (L) heel; and, 2. Resident 34's midline catheter (a catheter inserted into a vein in the upper arm with the tip located just below the armpit). This failure had the potential for Resident 49's and Resident 34's care needs and goals not being addressed. Findings: 1. During a review of Resident 49's Order Summary Report, dated 8/15/23, indicated, .PU (L heel) - Cleanse with NS [normal saline], pat dry, and [apply] silver alginate [treatment for PU], cover with foam dressing every day shift for 14 days . During an interview on 8/15/23 at 1:47 p.m. with Certified Nurse Assistant (CNA) 2, he confirmed Resident 49 had a pressure ulcer on the left heel. During an interview on 8/16/23 at 8:40 a.m. with Licensed Nurse (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 observation, interview, and record review, the facility failed to ensure 1 of 19 sampled residents (Resident 17), was provided nail care in a timely manner. This failure resulted in Resident 17 having long, and untrimmed fingernails and toenails that could potentially cause injury, pain, and infection. Findings: During a concurrent observation and interview on 8/15/23 at 10:39 a.m. with Resident 17 in Resident 17's room, Resident 17 had long and untrimmed fingernails and toenails on both hands and feet. Resident 17 stated her fingernails and toenails needed to be clipped (trimmed) and her family member asked staff to clip her nails about two weeks ago and still had not been done. During a concurrent observation and interview on 8/15/23 at 11:31 a.m., with Certified Nurse Assistant (CNA) 2 in Resident 17's room, CNA 2 confirmed Resident 17's fingernails and toenails were long and untrimmed. CNA 2 stated the nails needed attention and went on to say Resident 17's fingernails and toenails needed clipping by the responsible staff. CNA 2 also stated Resident 17 could scratch her…

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 implement preventative measures to reduce the risk of elopement (an act or instance when a cognitively impaired person leaves a safe area or premises unsupervised) for 1 of 19 sampled residents (Resident 16) when an elopement assessment was not completed after Resident 16 eloped the facility. This failure placed Resident 16 at an increased risk for elopement and physical harm due to her behavior of wandering in the facility. Findings: A review of Resident 16's admission Record indicated Resident 16 was admitted to the facility in 2023. During a concurrent observation and interview on 8/15/23 at 10:35 a.m. with Resident 16 in her room, Resident 16 was observed to be fully dressed in street clothes and was sitting on the side of her bed exposing a wanderguard bracelet (a monitoring device used to alert staff of a resident leaving the premises) on her left ankle. When asked why she had a bracelet around her left ankle, Resident 16 stated that one day she decided she did not want to live in the facility anymore,…

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 medication monitoring for high-risk medication use (drugs with potential to cause harm without monitoring) in 3 out of a sample of 19 residents (Resident 3, Resident 17, and Resident 19) when: 1. Resident 3 was prescribed high risk medications for diabetes (Blood Sugar Disease) without side effect monitoring or guidance for nursing staff for safe use; 2. Resident 17 was prescribed high risk anticoagulant (blood thinner) medications without side effect monitoring or a care plan which addressed specific symptoms to watch for; and, 3. High risk anticoagulant medications were not monitored for side effects on a regular basis for Resident 19. These failures could result in unsafe medication use and adverse consequences. Findings: 1. During a review of Resident 3's electronic medical record, titled Medication Administration Record (or MAR, a list of medications and interventions nursing staff followed and documented), dated 8/2023, the MAR indicated Resident 3 was taking medications to treat blood sugar disease as…

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

Based on observation, interview, and record review, the facility failed to ensure safe cleaning and sanitization of a shared glucometer (a device which measures blood sugar using blood from the fingertip) between resident care for two out of a census of 55 residents (Resident 43 and Resident 48). This failure could result in spread of infection and cross contamination of shared devices. Findings: During a medication administration observation with Licensed Nurse 1 (LN 1), on 8/15/23, at 8:52 AM, LN 1 measured Resident 43's blood sugar using a glucometer which was shared between residents. LN 1 used a lancet (a sharp piercing device) to pierce Resident 43's finger to get blood and then applied the blood to the test strip that was attached to the glucometer. LN 1 then exited the room and cleaned the glucometer's outer surface with one wipe for less than 10 seconds and placed it on top of a container storing blood sugar measuring supplies. During a medication administration observation with LN 2, on 8/15/23, at 9:48 AM, LN 2 measured Resident 48's blood sugar using a glucometer. LN 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 interview and record review, the facility failed to ensure appropriate use of antibiotic medication (used to treat bacterial infections) within the antibiotic stewardship program, for one of nine residents (Resident 48) when Resident 48's antibiotic order did not have an end date. This failure increased Resident 48's risk for an infection with bacterial organisms resistive to certain antibiotics (MDRO; multidrug-resistant organisms, germs that are resistant to many antibiotics) in the facility. Findings: Review of Resident 48's admission RECORD indicated Resident 48 was admitted to the facility in mid 2023. Review of Resident 48's Order Summary Report, indicated Resident 48 had a physician order for Doxycycline Hyclate [antibiotic medication used to treat bacterial infection] Oral Tablet 100 MG [milligram, a unit of measurement] .Give 1 tablet by mouth two times a day for UTI [urinary tract infection] ppx [prophylaxis, a treatment taken to prevent a disease] .Start Date .8/6/23 . There was no end date listed. Review of Resident 48's Medication Administration Record (MAR),…

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 19 sampled resident's (Resident 34) equipment was in safe operating condition, when Resident 34's call light had an exposed wire. This failure had the potential to affect Resident 34's safety, comfort, and well-being. Findings: During a concurrent observation and interview on 8/15/23 at 3:18 p.m. with Licensed Nurse (LN) 1 in Resident 34's room, Resident 34's call light was observed on top of the bed. LN 1 stated Resident 34's call light had an exposed red and black wire approximately 1 inch (unit of measurement) long. LN 1 pressed Resident 34's call light and stated the call light was still working. LN 1 stated a resident's call light with an exposed wire was not acceptable and it should be fixed. LN 1 further stated this could be a safety issue and there was the potential for Resident 34's call light to stop working. LN 1 explained Resident 34 used her call light to get help from staff. During an interview on 8/18/23 at 11:54 a.m. with the Maintenance Supervisor (MS), the MS acknowledged…

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.